Conduct disorder is a repetitive and persistent pattern of behavior in children and adolescents in which the rights of others or basic

social rules are violated. The child or adolescent usually exhibits these behavior patterns in a variety of settingsat home, at school, and in social situationsand they cause significant impairment in his or her social, academic, and family functioning. As listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. ( !"#$%&,' symptoms typically include aggression, fre(uent lying, running away from home overnight and destruction of property "any youth with conduct disorder may have trouble feeling and expressing empathy or remorse and reading social cues. These youth often misinterpret the actions of others as being hostile or aggressive and respond by escalating the situation into conflict. Conduct disorder may also be associated with other difficulties such as substance use, ris)#ta)ing behavior, school problems, and physical in*ury from accidents or fights. Conduct disorder is more common among boys than girls, with studies indicating that the rate among boys in the general population ranges from +, to '+, while the rate among girls ranges from -, to .,. Conduct disorder can have its onset early, before age '/, or in adolescence. Children who display early#onset conduct disorder are at greater ris) for persistent difficulties, however, and they are also more li)ely to have troubled peer relationships and academic problems. Among both boys and girls, conduct disorder is one of the disorders most fre(uently diagnosed in mental health settings.
Four types of symptoms of conduct disorder are recognized: (1) Aggression or serious threats of harm to people or animals; (2) Deliberate property damage or destruction (e.g., fire setting, vandalism); (3) Repeated violation of household or school rules, laws, or both; and (4) Persistent lying to avoid consequences or to obtain tangible goods or privileges.1 DSM-IV1 emphasizes that there should be at least three specific conduct disorder behaviors present for at least six months to make the diagnosis. Isolated behaviors (e.g., shoplifting, experimentation with marijuana or alcohol) are common, and specific antisocial acts may occur in up to 80 percent of youth in the United States.6 By contrast, a diagnosis of conduct disorder requires a persistent history of multiple problem behaviors. Associated features of conduct disorder include an inability to appreciate the importance of others' welfare and little guilt or remorse about harming others. Adolescents with conduct disorder often develop skills in outwardly verbalizing remorse to obtain favor or avoid punishment, but do not experience any apparent guilt. Patients with conduct disorder often view others as threatening or malicious without an objective basis. As a result, these children and adolescents may lash out preemptively, and aggression may appear unprovoked. Physicians should be able to distinguish between normal adolescent risk-taking and enduring antisocial behavior. In normal experimentation, offenses do not typically involve serious harm to individuals or property and do not persistently recur. Isolated or acting-out episodes with a recent onset, particularly

among adolescents without previous adjustment problems, are often transient reactions to external stressors. This pattern of behavior should prompt physicians to inquire about recent parental conflict or separation, geographic moves or school transitions.6 Among children 10 to 14 years of age, several health-related behaviors are red flags for conduct disorder. These include cigarette smoking, sexual activity, and alcohol or drug use.7

Subtypes of Conduct Disorder

Conduct disorder has two subtypes: childhood onset and adolescent onset. Childhood conduct disorder, left untreated, has a poorer prognosis. Behaviors that are typical of childhood conduct disorder include aggression, property destruction (deliberately breaking things, setting fires) and poor peer relationships. In about 40 percent of cases, childhood onset conduct disorder develops into adult antisocial personality disorder.8 Adolescent conduct disorder should be considered in social context. Adolescents exhibiting conduct disorder behavior as a part of gang culture or to meet basic survival needs (e.g., stealing food) are often less psychologically disturbed than those with early childhood histories of behavior disorders. Additionally, new-onset conduct disorder behavior, such as skipping school, shoplifting or running away, in the context of a family stressor, often remits if appropriate structure and support are provided.

Etiology
The etiology of conduct disorder involves an interaction of genetic/constitutional, familial and social factors. Children who have conduct disorder may inherit decreased baseline autonomic nervous system activity, requiring greater stimulation to achieve optimal arousal.9 11 This hereditary factor may account

for the high level of sensation-seeking activity associated with conduct disorder.10 Current research focuses on defining neurotransmitters that play a role in aggression, with serotonin most strongly implicated.11 Parental substance abuse, psychiatric illness, marital conflict, and child abuse and neglect all increase the risk of conduct disorder. Exposure to the antisocial behavior of a caregiver is a particularly important risk factor.12 Children with conduct disorder, while present in all economic levels, appear to be overrepresented in lower socioeconomic groups.10 Another common feature appears to be inconsistent parental availability and discipline.10 13 As a result, children with conduct disorder do not experience a
,

consistent relationship between their behavior and its consequences. This early childhood pattern includes irritability, inconsolability and impaired social responsiveness.14 15
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Caregivers, particularly those with psychiatric conditions and substance abuse problems, may respond to these children coercively and inconsistently. In addition, these family groups often experience financial distress, which may further complicate the situation. These children are also more susceptible to the rise in peer group influence that typically occurs in later elementary school.

Differential Diagnosis and Comorbidity

Several common childhood psychiatric conditions have features similar to those of conduct disorder, and comorbid conditions are also common.11 The differential diagnosis should include attentiondeficit/hyperactivity disorder (ADHD), oppositional defiant disorder, mood disorder (major depression, dysthymia, bipolar disorder), substance abuse and intermittent explosive disorder Oppositional defiant disorder may be difficult to distinguish from conduct disorder. Key features of oppositional defiant disorder include argumentativeness, noncompliance with rules and negativism. While these features partially overlap with those of conduct disorder, there are important distinctions. Children with oppositional defiant disorder, although argumentative, do not display significant physical aggression and are less likely to have a history of problems with the law. Parents of children with oppositional defiant disorder are more likely to have mood disorders than the antisocial pattern common among parents of children who have conduct disorder. Oppositional defiant disorder may, with time, develop into conduct disorder. Significant acting out frequently occurs among children and adolescents with major depression and dysthymic disorder. Patients with early-onset bipolar disorder may exhibit impulsive violations of rules and aggression. However, mood disorders typically include disturbances of sleep and appetite and pronounced affective symptoms, as well as significant alterations in energy and activity levels not found among children with conduct disorder. The coexistence of major depression with conduct disorder increases the risk of impulsive suicidal behavior. Substance abuse may also overlap with the symptoms of conduct disorder. A key issue in assessing substance use in adolescents is the distinction between experimentation and abuse or dependence. The frequency and duration of substance use are helpful dimensions in this regard. Early (i.e., at 10 to 13 years of age), repeated use of alcohol or illicit drugs is a red flag for the development of other behaviors associated with conduct disorder. Additionally, substance use is likely to further reduce impulse control and increase contact with deviant peers.16 Intermittent explosive disorder, featuring unprovoked, sudden aggressive outbursts, can only be correctly diagnosed when the child's behavior does not meet the criteria for conduct disorder. Patients with intermittent explosive disorder deny plans to harm anyone but report that they snapped or popped and, without realizing it, assaulted another person. In children and adolescents with intermittent explosive disorder, these episodes are the only signs of behavior disturbance. Other than unplanned acts of aggression, patients with intermittent explosive disorder do not engage in repeated violations of other rules or in illegal behavior such as theft or running away from home.

Conduct disorder is a ma*or public health problem because youth with conduct disorder not only inflict serious physical and psychological harm on others, but they are at greatly increased ris) for incarceration, in*ury, depression, substance abuse, and death by homicide and suicide. The syndrome is not a single medical entity but encompasses various forms of 0ma*or misbehaviour0. 1-2 After the age of '3, a conduct disorder may develop into antisocial personality disorder, which is related to psychopathy.142 epressive conduct disorder is a combination of conduct disorder with persistent and mar)ed depression of mood with symptoms such as loss of interest, hopelessness, disturbances in sleep patterns and altered appetite142 Conduct disorder is a childhood behavior disorder characterized by aggressive and destructive activities that cause disruptions in the child's natural environments such as home, school, church, or the neighborhood. The overriding feature of conduct disorder is the repetitive and persistent pattern of behaviors that violate societal norms and the rights of other people. It is one of the most prevalent categories of mental health problems of children in the United States, with rates estimated at ! for males and "! for females.

Description
The specific behaviors used to produce a diagnosis of conduct disorder fall into four groups# aggressive conduct that causes or threatens physical harm to other people or animals, nonaggressive behavior that causes property loss or damage, deceitfulness or theft, and serious violations of rules. Two subtypes of conduct disorder can be delineated based on the age that symptoms first appear. Childhood$onset type is appropriate for children showing at least one of the behaviors in %uestion before the age of &'. (dolescent onset type is defined by the absence of any conduct disorder criteria before the age of &'. Severity may be described as mild, moderate or severe, depending on the number of problems e)hibited and their impact on other people. *oungsters who show symptoms +most often aggression, before age &' may also e)hibit oppositional behavior and peer relationship problems. -hen they also show persistent conduct disorder and then develop adult antisocial personality disorder , they should be distinguished from individuals who had no symptoms of conduct disorder before age &'. The childhood type is more highly associated with heightened aggression, male gender, oppositional defiant disorder , and a family history of antisocial behavior.

The individual behaviors that can be observed when conduct disorder is diagnosed may be both common, problematic, and chronic. They tend to occur fre%uently and are distressingly consistent across time, settings, and families. .ot surprisingly, these children function poorly in a variety of places. In fact, the behaviors clustered within the term /conduct disorder/ account for a ma0ority of clinical referrals, classroom detentions or other sanctions, being as1ed to stop participating in numerous activities, and can be e)tremely difficult +even impossible, for parents to manage. The negative conse%uences of conduct disorder, particularly childhood onset, may include illicit drug use, dropping out of school, violent behavior, severe family conflict, and fre%uent delin%uent acts. Such behaviors often result in the child's eventual placement out of the home, in special education and2or the 0uvenile 0ustice system. There is evidence that the rates of disruptive behavior disorders may be as high as 3'! in youth in public sectors of care such as 0uvenile 0ustice, alcohol and drug

The overriding feature of conduct disorder is the repetitive and persistent pattern of behaviors that violate societal norms and the rights of other people. Youngsters with conduct disorder often exhibit aggressive behavior to other people (bullying, starting fights, etc.) or to animals. They may also damage others' property. +Carolyn (. 4c5eone. 6hoto 7esearchers, Inc. 7eproduced by permission., services, schools for youths with serious emotional disturbances, child welfare, and mental health.

The financial costs of crime and correction for repeated 0uvenile offenses by youth with conduct disorder are e)tensive. The social costs include citizens' fear of such behavior,

loss of a sense of safety, and disruptions in classrooms that interfere with other children's opportunity to learn. The costs to the child and his or her family are enormous in terms of the emotional and other resources needed to address the conse%uences of the constellation of symptoms that define conduct disorder.

auses and symptoms

There is no 1nown cause for conduct disorder. The frustrating behavior of youngsters with conduct disorder fre%uently leads to blaming, labeling, and other unproductive activities. Children who are /acting out/ do not inspire sympathy or the benefit of the doubt. They are often ostracized by other children. 6arents of such children are often blamed as poor disciplinarians or bad parents. (s a result, parents of children with conduct disorder may be reluctant to engage with schools or other authorities. (t the same time, there is a strong correlation between children diagnosed with conduct disorder and a significant level of family dysfunction, poor parenting practices, an overemphasis on coercion and hostile communication patterns, verbal and physical aggression and a history of maltreatment. There is a suggestion of an, as yet, unidentified genetic component to what has generally been viewed as a behavioral disorder. 8ne study with adopted children in the mid$& loo1ed at the relationship between birth parents with antisocial personality disorder, and adverse adoptive home environments. -hen these two adverse conditions occurred, there was significantly increased aggressiveness and conduct disorder in the adopted children. That was not the case if there was no indication of antisocial personality disorder in the birth parents. This finding has important implications for prevention and intervention of conduct disorders and its associated conditions of substance abuse and aggressiveness. 's

Symptoms
The Diagnostic and Statistical Manual of Mental Disorders +also 1nown as the DSM-IV-TR , indicates that for conduct disorder to be diagnosed, the patient has repeatedly violated rules, age$appropriate social norms and the rights of others for a period of at least twelve months. This is shown by three or more of the following

behaviors, with at least one having ta1en place in the previous si) months# aggression to people or animals, property destruction, lying or theft, and serious rule violations. (ggression to people or animals includes#

engaging in fre%uent bullying or threatening often starting fights using a weapon that could cause serious in0ury +gun, 1nife, club, bro1en glass, showing physical cruelty to people showing physical cruelty to animals engaging in theft with confrontation +armed robbery, e)tortion, mugging, purse snatching,

forcing se) upon someone

6roperty destruction includes#

deliberately setting fires to cause serious damage deliberately destroying the property of others by means other than fire setting

9ying or theft includes#

brea1ing into building, car, or house belonging to someone else fre%uently lying or brea1ing promises for gain or to avoid obligations +called /conning/, stealing valuables without confrontation +burglary, forgery, shop lifting,

Serious rule violations include#

beginning before age &:, fre%uently staying out at night against parents' wishes running away from parents overnight twice or more or once if for an e)tended period engaging in fre%uent truancy beginning before the age of &:

4ild severity would mean there are few problems with conduct beyond those needed to ma1e a diagnosis (.; all of the problems cause little harm to other people. 4oderate severity means the number and effect of the conduct problems is between the e)tremes of mild and severe. Severe is indicated if there are many more conduct symptoms than are needed to ma1e the diagnosis +more than three in the previous twelve months or more than one in the previous si) months,, or, the behaviors cause other people considerable harm.

Diagnosis
Conduct disorder is generally diagnosed when somebody, often a child in school, comes to the attention of authorities +school, law enforcement, and others, most often because of behavior. The person might then be referred to a psychiatrist or psychologist for assessment and diagnosis . It is unli1ely that any sort of specific test is given< rather, the individual would have to meet the criteria in the DSM-IV-TR. Usually there is a history of acting out in school, neighborhood, home, and other social settings. Court$ ordered treatment would li1ely occur if the person comes to the attention of the police and if a crime is involved. ( 0udge might order treatment as an alternative to 0ail, or before a sentence is served.

Treatments
=arlier treatments of youth with conduct disorder relied on legal processes to declare a child in need of supervision or treatment and thus able to be placed in residential settings established for this purpose. -hile residential placements may still be used, recent treatment models have relied less on such restrictive procedures. The increased visibility and sophistication of the consumer movement, comprised of families of children and youth with mental health disorders, is bringing pressure to bear on treatment providers to stop blaming families, stop removing children from their families for services, focus instead on strengths and assets in both the child and his or her family, and to use community$based interventions in several domains in which the child and family live.

Community$based interventions are sometimes called wrap$around services to describe the intention that they will be brought to the child's natural environment in a comprehensive and fle)ible way. The idea is to target a range of child, parent, family and social system factors associated with a child's behavioral problems. This approach has been successful in modifying antisocial behavior, rates of restrictive placement, and in reducing the cost of services. (nother treatment that has been used with some success is the Child Cognitive Behavioral Treatment and Skills Training which trains children with conduct disorder in anger$coping, peer coping, and problem$solving s1ills. !arent "anagement Training and family therapy are also used to treat conduct disorder. 6arents learn to apply behavioral principles effectively, how to play with their children, and how to teach and coach the child to use new s1ills. 4edication is sometimes used and may be effective in controlling aggression. >enerally, a variety of treatment modes are used to address such a comple) disorder. Severe antisocial behavior on the part of the child and adverse parenting practices may suggest that the family will stop treatment before it can be effective, or before meaningful change can result.

!rognosis
=arly identification and appropriate and innovative treatment will improve the course of conduct disorder and possibly prevent a host of negative outcomes that are often a conse%uence of the behaviors associated with it. Unfortunately, the stigma of treatment and the undiagnosed problems of many parents are still significant enough that families whose children could benefit from treatment never find their way to a treatment setting. Instead their children come into contact with the 0uvenile and criminal 0ustice system.

!revention
6rognosis may best be improved by prevention of conduct disorder before it becomes so resistant to treatment. 7esearch is being conducted on what early interventions hold the

greatest promise. The research incorporates several components such as child tutoring, classroom intervention, peer training, social$cognitive s1ills training, parent training, and family problem$solving. 8ther studies have included early parent or family interventions, school$based interventions and community interventions. (gain, these include a variety of elements as suggested before, including parent training that includes education about normal child development, child problem$solving, and family communication s1ills training. 7esearch is still needed to determine where and when to target specific preventive interventions.