Conduct Disorder

What conduct disorder is, and what it is not

Conduct disorder is a diagnosis used with children and young people, and the adults involved are usually parents, grandparents, foster carers or teachers. The words often reach a family through a school or a clinic. Two points come before the detail.

The first is that medication is not indicated for conduct disorder itself.¹ The research emphasises psychosocial treatment; psychosocial means talking and training-based work done with the child and the family. Parent management training is such an approach, and it works with the parent rather than only with the child.²

The second is that timing counts: age and severity are the most important known predictors of how treatment goes. A younger child, whose behaviour is less disruptive, has a better chance of doing well.³

Conduct disorder describes a repeated pattern of behaviour that breaks the basic rights of others, or the everyday rules and norms expected at a child's age. One difficult incident does not make the diagnosis. Clinicians look for a pattern that repeats and persists over time.⁴

It also has to be causing real difficulty in a child's life, whether that shows at home, at school, with friends, or across all three.

Estimates of how common it is vary: the DSM-5 puts one-year population estimates between 2% and more than 10%; the median is 4%.

Prevalence appears fairly consistent across countries that differ in race and ethnicity.¹⁶

The condition carries two names. The World Health Organization's ICD-11 calls it conduct-dissocial disorder.⁴ The American manual, the DSM, keeps the name conduct disorder. It sorts the behaviour into four areas.⁵

The two systems set their thresholds differently. ICD-11 asks for repeated incidents over an extended period, for example at least a year.⁴ The DSM asks for at least 3 of the 15 listed behaviours in the past 12 months. At least one of them must fall in the past 6 months.⁵

So the term on a clinic letter may not be the one that appears online, and neither is wrong; which manual a clinician uses depends on the country.

How it shows up

Both manuals describe the same four kinds of behaviour. Living with these behaviours is usually more ordinary, and more tiring, than the list suggests.

• Aggression towards people or animals: bullying, threatening others, starting fights, using a weapon, or hurting an animal.⁴
• Destroying property: setting a fire deliberately to cause serious damage, or deliberately damaging what belongs to someone else.⁴
• Lying or stealing: shoplifting, breaking into a house or car, or lying to get out of trouble.⁴
• Serious rule-breaking: staying out all night, running away from home, or missing school without permission.⁴

A list cannot show what this is like at home. The same argument repeats; the school calls again; the child is out of the house, and nobody knows where.

A parent, a teacher or a website cannot make the diagnosis, because it rests on a full assessment rather than a checklist.

Oppositional defiant disorder, ADHD, and what else to look for

Oppositional defiant disorder is a closely related diagnosis, historically understood as the less severe pattern, and the one that commonly comes first. Conduct disorder is the more severe picture, and it commonly follows it. The two can also be diagnosed together.⁶

Attention deficit hyperactivity disorder, or ADHD, is a different thing again, and it often turns up alongside conduct disorder. So do learning difficulties, anxiety, low mood and substance use.⁶

That overlap has practical consequences, because a child can be treated for the behaviour while a condition sitting alongside it goes unnoticed. Canadian guidance strongly recommends stimulants for oppositional behaviour, conduct problems and aggression in young people with ADHD.¹ A good assessment looks for all of it.⁷

Why the age it started matters

One of the more useful questions a clinician asks is when this began. ICD-11 separates an early start from a later one, at around age 10.⁸

Neither column is a prediction about one child. An early start also does not mean the specifier described below applies.⁸ The two are judged separately.

A report may also grade severity as mild, moderate or severe, and that grading rests on three things. How often the symptoms occur, how severe they are, and the harm they cause.⁵

Limited prosocial emotions, and who the specifier fits

Callous-unemotional traits is another phrase attached to this diagnosis, and both manuals carry it as a specifier, named limited prosocial emotions. A specifier is an extra label a clinician may add to a diagnosis.

It describes limited empathy or remorse, little concern about doing badly, and shallow feeling towards other people. Children who fit that pattern are a minority of those diagnosed with these disruptive behaviour disorders. It is the relatively more severe and less common presentation, and not what this diagnosis usually looks like.⁹

Where the pattern is genuinely present it appears to be moderately heritable, and it identifies young people whose difficulties are more likely to persist. They show more planned, goal-driven aggression than other children with the diagnosis, and their adult risk is higher.¹⁰

The specifier is therefore neither trivial nor common, and a clinician does not apply it on one incident or one relationship. The pattern has to hold across settings and over time.⁹ It also needs more than the child's own account.

Why did this happen, and is it my fault?

There is no single cause, and no one event explains it; what the evidence supports is a cumulative picture.

Risk factors seldom act alone: they interact, they reinforce each other, and many last for years. What matters most is not which risk a child has. It is how many, and for how long.¹¹

These are the risk factors the research names.

• Male sex, and lower cognitive ability.¹²
• Poverty in childhood.¹²
• A parent's substance use or criminal history, and smoking during pregnancy.¹²
• Physical or sexual abuse, or violence between parents at home.¹²
• Family instability, meaning changes in who is parenting the child.¹²
• Harsh discipline, or a parent who is cruel or rejecting.¹²
• Friends who use substances, skip school or offend.¹²

The list is not an accusation, though it can read as one, and it describes what turns up more often across large groups of children. The factors act together, and no single one of them explains a child.

A hard week of parenting does not produce this. Parents are central to treatment because that is where the work has been shown to succeed.² Their involvement is not a judgement on them.

What an assessment involves

An assessment is not one appointment and a checklist. A clinician will want more than one account of what is happening.⁷ That means hearing from the parents, from the child, and often from the people who see the child every day.

The child will be asked directly, and how that is done matters. Young people give reliable accounts when they are not judged or pressed.⁷

Rating scales are often used to gauge how severe and how widespread the difficulties are. The clinician should also screen for what commonly sits alongside conduct disorder. That list includes ADHD, depression, bipolar disorder, substance use, developmental delay and learning difficulties.⁷

Missing one of those is how a child ends up treated for the wrong thing. Ask what is being screened for; it is a fair question and a clinician will not mind it.

What actually helps

The first-line help, meaning what is tried first, is psychosocial. For younger children, parent management training is the main psychosocial treatment. It teaches consistent parenting, calmer and clearer discipline, consistent monitoring, and noticing what goes right. Measured against control conditions, these programmes generally appear effective in reducing defiance, non-compliance and aggression in young children.²

Work with the child runs alongside that: skills programmes teach problem-solving, getting on with others, and handling anger. Family therapies have shown promise, functional family therapy among them.²

Programmes that combine parent training, family therapy and child skills work show a medium to large effect. That effect is on preventing conduct problems from worsening in children already at risk.² Many keep their gains after treatment ends.

For teenagers with a settled pattern, specific programmes exist. Multisystemic treatment and multidimensional treatment foster care were designed for older children and adolescents. Their antisocial and aggressive behaviour was serious enough to involve the justice system.²

The work happens in the family and the community, not with the child alone in a room. Best practice draws in the positive influences around a young person. It teaches parenting and problem-solving skills, and keeps families and professionals working together.¹³

Occasionally a hospital admission is needed. That is for a dangerous situation, or as a safe place to start treatment for something else.¹³

In children who are already aggressive, short structured parent programmes reduce symptoms for up to four months; those studies vary in quality. More intensive programmes that involve the child tend to do better.³

So the type of programme matters, not only that a programme is offered. The earlier the work starts, the more there is to work with.

Where medication fits

Medication is not the centre of treatment for conduct disorder, and guidance in the United Kingdom is direct about it. It advises against prescribing for the routine management of behaviour problems in conduct disorder.¹

Medication has two narrower places: the first is a condition sitting alongside it, ADHD above all. Canadian guidance strongly recommends stimulants for children and teenagers who have ADHD.¹ That includes the oppositional behaviour, conduct problems and aggression that come with it.

The second is severe aggression or explosive anger. Risperidone is an antipsychotic medicine. The UK guidance allows risperidone there, short term, and only once any ADHD has been treated.¹

Low doses can reduce explosiveness and reactive anger, and there are side effects. They include tiredness and weight gain, and weight gain is a common one.¹⁴

Weight gain can come with raised blood fats and insulin resistance, where the body handles sugar less well. Tardive dyskinesia, a pattern of involuntary movements, has been reported with nearly all antipsychotics.

Risperidone is one of the newer antipsychotics, the group called atypical. Tardive dyskinesia appears much less likely with those than with the older, typical ones.¹⁴ A child taking one needs proper monitoring, and that monitoring is part of prescribing well.

Will my child grow out of this?

The answer has two parts, and both are true. The course varies a great deal from one young person to the next.¹⁵

In a majority of young people the disorder remits by adulthood, meaning they no longer meet the criteria for the diagnosis. Many young people with conduct disorder adjust adequately, socially and at work, as adults. That is particularly true of those with adolescent onset, and with few and milder symptoms.¹⁷

The second part is harder: an earlier start and greater severity both predict a worse outcome. Those young people more often have trouble with the law and with substances. Other mental health conditions are more common for them in adulthood.¹⁵

Those are population patterns, not verdicts on an individual child. Behaviour also tends to start at the milder end, lying rather than violence.¹⁵ It may grow more serious over time.

Early help is the part that can be acted on.³ It is not a promise, and it does change what is likely.

Living with it day to day, and staying safe

This is exhausting to live with; the exhaustion is not a failure of love, and it is not a character flaw.

First, the strategies that work are taught and practised with support, which is what parent training is. A webpage is not a substitute for it, and this one is not.

Second, where behaviour is putting anyone at risk, that calls for an assessment rather than advice off a page. That includes risk to the child. Young people with conduct disorder are at raised risk of suicide. Suicidal thinking and suicide attempts also occur more often than expected.¹⁶

That is a population rate, not a prediction about a particular child. Tell the clinician plainly what you have seen. If there is immediate danger, use the emergency numbers.

Look after yourself as well, and not as an afterthought. Most of the treatment work happens with you. Carers who are supported can keep going, and this work takes time.

Where to start

Ask for an assessment with a clinician who works with children and young people. You do not need a diagnosis before making that call, nor does the behaviour need to get worse first.

Few children whose conduct disorder is impairing them actually receive treatment.¹⁶ Asking for help early is not fussing.

The main points:

• A pattern, not one incident, is what this diagnosis describes.
• The first-line help is psychosocial, and it involves you.
• Medication is not indicated for conduct disorder itself. It has two narrower places: a condition such as ADHD, and short-term use for severe aggression.¹
• The limited prosocial emotions specifier fits a minority of children with disruptive behaviour disorders.⁹
• Going earlier gives treatment more to work with.

A starting point is our guide on choosing a therapist. It covers what to ask, and what a good fit looks like.

This page is information, and it is not an assessment. It cannot tell you what is happening for your child, and we cannot respond in real time. For that you need a clinician who can meet them.