Conduct Disorder - Anatomy of Psych

What is conduct disorder?

Conduct disorder is a disruptive disorder characterized by a repetitive and persistent pattern of behavior in which the basic rights of others, societal norms, or rules are violated.

There are 4 main categories of the behavior:

Aggressive conduct, causing harm to people or animals
Non-aggressive conduct, causing damage to or loss of property
Deceitfulness or theft
Serious violation of rules

The yearly prevalence rate in the United States is 2-10%, and is more common in men/boys than women/girls.

What does conduct disorder look like?

DSM-5 Criteria

Criterion A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least 3 of the following 15 criteria in the past 12 months from any of the categories below, with at least 1 criterion present in the past 6 months:

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 (e.g. a bat, brick, broken bottle, knife, gun)
Has been physically cruel to people
Has been physically cruel to animals
Has stolen while confronting a victim (e.g. mugging, purse snatching, extortion, armed robbery)
Has forced someone into sexual activity

Destruction of Property

Has deliberately engaged in fire setting with the intention of causing serious damage
Has deliberately destroyed others’ property (other than by fire setting)

Deceitfulness or Theft

Has broken into someone else’s house, building, or car
Often lies to obtain goods or favors or to avoid obligations
Has stolen items of nontrivial value without confronting a victim (e.g. shoplifting, but without breaking and entering; forgery)

Serious Violation of Rules

Often stays out at night despite parental prohibitions, beginning before age 13 years
Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period
Is often truant from school, beginning before age 13 years

Criterion B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

Criterion C. If the individual is 18 years or older, criteria are not met for antisocial personality disorder

Subtypes & Specifiers

Subtypes:

Childhood-onset
Adult-onset
Unspecified

Specifiers:

Onset specifier:
- Childhood-onset type: at least 1 symptom before age 10
- Adolescent-onset type: no symptoms prior to age 10
- Unspecified onset
With limited prosocial emotions:
- At least 2 of the following characteristics displayed persistently over at least 12 months and in multiple relationships and settings:
  - Lack of remorse or guilt
  - Callous - lack of empathy
  - Unconcerned about performance
  - Shallow or deficient affect

Risk Factors

More common in children whose parents have severe alcohol use disorder, depressive disorders, bipolar disorders, schizophrenia, ADHD, and conduct disorder
Difficult infant temperament and low intelligence (especially verbal IQ)
Adverse childhood events; exposure to violence in the neighborhood
Peer rejection
Association with delinquent peer groups
Poverty in childhood
Maternal smoking during pregnancy
Paternal substance use disorders or criminal behavior
Oppositional defiant disorder is often a precursor to childhood-onset conduct disorder

Prognosis

Behaviors can lead to school suspension/expulsion, problems at work, legal difficulties, unplanned pregnancy, sexually transmitted diseases, and injuries from accidents or fights
Roughly 40% of minors with conduct disorder will become adults with antisocial personality disorder

Differential Diagnosis

Oppositional defiant disorder
Attention-deficit/hyperactivity disorder
Depressive disorders
Bipolar disorders
Intermittent explosive disorders
Adjustment disorders

How is conduct disorder investigated?

Psychoeducational testing for individuals with suspected learning disability

How is conduct disorder treated?

There are no medications that treat conduct disorder. However, it is important for any co-morbid conditions, such as ADHD, to be treated. Psychosocial interventions, are important for long-term management. This includes:

Family support:
- Supporting clear, direct, and positive communication within the family
- Stress reduction in the home, including the avoidance of harsh discipline
- Encouraging participation in organizations such as Big Brothers Big Sisters or other community or religious groups that can provide positive role models for appropriate behavior
Brief strategic family therapy
Problem-solving skills training

Nursing Management

Risk for other-directed violence

Causes & Behaviors:

Characteristics of temperament
Peer rejection
Negative parental role models
Dysfunctional family dynamics

Interventions:

Observe client’s behavior frequently through routine activities and interactions; become aware of behaviors that indicate a rise in agitation and intervene accordingly
Redirect violent behavior with physical outlets for suppressed anger and frustration to promote relaxation
Encourage the client to express anger in appropriate ways, and offer discussion with the client on how to manage their emotions in effective ways

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] Lillig, M. (2018). Conduct disorder: Recognition and management. American Family Physician, 98(10), 584–592.

[4] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.