Conduct Disorder: Recognition and Management

 

Conduct disorder is a psychiatric syndrome that most commonly occurs in childhood and adolescence. It is characterized by symptoms of aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules. Risk factors include male sex, maternal smoking during pregnancy, poverty in childhood, exposure to physical or sexual abuse or domestic violence, and parental substance use disorders or criminal behavior. At least three symptoms should have been present in the past 12 months, with at least one present in the past six months to diagnose conduct disorder. Interventions consist of treating comorbid conditions such as attention-deficit/hyperactivity disorder; supporting clear, direct, and positive communication within the family; and encouraging the family and youth to connect with community resources. There are several evidence-based psychosocial interventions that a psychologist or therapist may implement as part of long-term treatment. Currently, no medications have been approved by the U.S. Food and Drug Administration to treat conduct disorder. Treatment with psychostimulants is highly recommended for patients who have both attention-deficit/hyperactivity disorder and conduct problems. There is some evidence to support the treatment of conduct disorder and aggression with risperidone, but health care professionals should weigh the medication's potential benefits against its adverse metabolic effects.

Conduct disorder is a psychiatric syndrome that most commonly occurs during childhood and adolescence. Conduct disorder is characterized by repetitive, persistent violations of both the rights of others and age-appropriate societal norms. The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), outlines 15 possible criteria for conduct disorder in the categories of aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules (Table 1).1 The estimated lifetime prevalence of conduct disorder in the United States is 9.5%, with a lifetime prevalence of 12% for males and 7.1% for females.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

In patients with conduct disorder, comorbidities such as ADHD should be identified and treated.

C

15, 16, 22, 23, 25

Recommendation from consensus guidelines from the United Kingdom (National Institute for Health and Care Excellence guidelines) and Canada

Psychosocial intervention should be used as a first-line treatment for conduct disorder symptoms that persist after comorbidities such as ADHD are treated.

C

22, 23, 25

Recommendation from consensus guidelines from the United Kingdom, Canada, and the United States

Risperidone (Risperdal) may benefit patients with conduct disorder who have severe aggression or explosive anger after comorbid ADHD is treated (if applicable).

C

22, 23, 25

Recommendations from consensus guidelines based on randomized controlled trials


ADHD = attention-deficit/hyperactivity disorder.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

In patients with conduct disorder, comorbidities such as ADHD should be identified and treated.

C

15, 16, 22, 23, 25

Recommendation from consensus guidelines from the United Kingdom (National Institute for Health and Care Excellence guidelines) and Canada

Psychosocial intervention should be used as a first-line treatment for conduct disorder symptoms that persist after comorbidities such as ADHD are treated.

C

22, 23, 25

Recommendation from consensus guidelines from the United Kingdom, Canada, and the United States

Risperidone (Risperdal) may benefit patients with conduct disorder who have severe aggression or explosive anger after comorbid ADHD is treated (if applicable).

C

22, 23, 25

Recommendations from consensus guidelines based on randomized controlled trials


ADHD = attention-deficit/hyperactivity disorder.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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TABLE 1.

DSM-5 Diagnostic Criteria for Conduct Disorder

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

The Author

MATHIAS LILLIG, MD, is an assistant professor of psychiatry, director of Child Psychiatric Services, and director of the Adolescent Inpatient Psychiatric Service at the University of Kansas School of Medicine–Wichita.

Address correspondence to Mathias Lillig, MD, University of Kansas School of Medicine, 1010 N. Kansas, Wichita, KS 67214. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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