Conduct Disorder

Key Points

• Poorer prognosis for conduct disorder is associated with earlier age at onset, lower IQ, more conduct symptoms, greater frequency, and severity of symptoms.

• Suspect alcohol and drug use in a teenager with conduct disorder.

• Talking to the CD adolescent is not sufficient; collateral sources of information (parents, teachers, courts) are essential.

• Diligently search for another, more treatable condition, if it exists, because CD does not have effective treatment.

• Involvement by the juvenile court or placement outside the home may be the best option for some patients.

The prevalence of conduct disorder (CD) in children under

18 years old is 6% to 16% in males and 2% to 9% in females.

At all ages, boys outnumber girls. Males usually exhibit more aggression, whereas females usually commit more covert crimes and prostitution. CD is more common in urban than rural settings and is one of the most frequent diagnoses in outpatient and inpatient psychiatric facilities for children. The mortality rate for seriously disturbed delinquents is 50 times higher than for normal youths. Adolescents with CD are more likely to die by homicide, suicide, violent accident, or drug overdose.

Generally, the natural history of children with severe CD is marked by the development of ADHD at a very early age, followed by ODD, then finally the onset of CD. In adolescence, alcohol and substance abuse occur. The factors that determine a poorer prognosis in the patient with CD are an early age of onset of symptoms, greater number of symptoms, and greater frequency of expression of these CD symptoms. The factors that determine a better prognosis are minimum number of CD symptoms, absence of comorbid psychiatric diagnoses, and normal intellectual functioning. Characteristics more common in childhood-onset versus adolescent-onset CD are greater frequency of neuropsychiatry disorders, lower IQ, higher levels of aggression, male gender, and greater frequency of externalizing behavior disorders in other family members. From 25% to 40% of children with CD go on to develop antisocial personality disorder, a chronic pattern of lawlessness.

Current views posit an interaction among genetic, biologic, and environmental factors (i.e., parental, sociocultural, psychological, prolonged abuse). No single factor accounts for more than 50% of the variance in the occurrence of CD, and no combination of factors accounts for more than 70% of the variance. Many children with risk factors do not develop CD.

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