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Mental Health

Conduct disorder

Common and highly impairing psychiatric disorder that usually emerges in childhood/adolescence and is characterized by severe antisocial and aggressive behaviour.

Introduction

Common and highly impairing psychiatric disorder that usually emerges in childhood/adolescence and is characterized by severe antisocial and aggressive behaviour.

  • CD affects ~3% of school-aged children and is twice as prevalent in males than in females.

DSM-5 | Disruptive, impulse control & conduct disorders (DIC):

Characterized by impulse behaviour (lack of self-control).

  • Oppositional defiant disorders (ODD)
  • Conduct disorder (CD)
  • Antisocial personality disorder
  • Intermittent explosive disorder (IED)
  • Impulse control disorder:
    • Pyromania (driven by compulsion)
    • Kleptomania

Types

Childhood-onset CD (more severe):

  • Begins at < 10 years

Adolescence-onset CD:

  • Begins at 10-18 years

Aetiology

Risk factors:

  • Male sex
  • Maternal smoking during pregnancy
  • Poverty in childhood
  • Exposure to physical/sexual abuse or domestic violence
  • Parental substance use disorders
  • Criminal behaviour
Environmental and dispositional risk factors for CD: Environmental and dispositional risk factors for conduct disorder (CD) and conduct problems operate at different stages in the lifespan. The importance of these risk factors varies depending on the developmental stage. For example, harsh and inconsistent discipline is more likely to be important in influencing risk during childhood whereas associating with deviant peers is more likely to be important duringadolescence. Along similar lines, temperamental factors in infancy may increase the risk of later CD whereas personality traits in childhood or adolescence may confer an increased risk of CD. Genetic factors exert their effects across all developmental stages. Furthermore, some risk factors might be more important for certain subtypes of CD; for example, genetic factors are thought to have a more important role in the development of antisocial behavior in youths with CD and callous-unemotional (CU) traits, with minimal effects of shared environmental influences, whereas genetic and shared environmental influences are equally important in youths with CD without CU traits. Some of these effects of environmental risk factors may be mediated through epigenetic alterations to produce the phenotype of CD, which is characterized by alterations on a molecular level, on a brain network level, and on a behavioral leve | Fairchild, G., Hawes, D. J., Frick, P. J., Copeland, W. E., Odgers, C. L., Franke, B., … De Brito, S. A. (2019). Conduct disorder. Nature Reviews Disease Primers, 5(1), 43. https://doi.org/10.1038/s41572-019-0095-y

Co-morbidities:

  • Attention-deficit/hyperactivity disorder (ADHD) (M/C)
  • Oppositional defiant disorder (ODD) (often precedes the onset of conduct disorder)
  • Substance use disorder
  • Mood disorder

Pathophysiology

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Graphical representation of the concept of developmental psychopathy, from a personality-based psychopathology (upper side) as well as a DSM-5 oriented (lower side) perspectives. | GM: grandiose-manipulative, DI: daring-impulsive, CU: callous-unemotional | Pisano, S., Muratori, P., Gorga, C., Levantini, V., Iuliano, R., Catone, G., … Masi, G. (2017). Conduct disorders and psychopathy in children and adolescents: aetiology, clinical presentation and treatment strategies of callous-unemotional traits. Italian journal of pediatrics, 43(1), 84. doi:10.1186/s13052-017-0404-6

Clinical features

CD is characterized by repetitive, persistent violations of both the rights of others and age-appropriate societal norms.

Conduct disorder (CD) is associated with functional impairments across the lifespan: The earliest impairments occur in educational and social domains, with children with CD frequently being excluded from school or taught in specialist educational settings and being rejected by their peers owing to aggressive or disruptive behaviour. CD is also associated with a high physical and mental health burden, with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder and developmental language disorders common comorbidities in childhood and adolescence and depression, anxiety and alcohol and substance use disorders frequently emerging in adolescence. Antisocial personality disorder or borderline personality disorder can occur in the transition to adulthood, along with serious criminal behaviour and gang involvement. Many individuals with CD become involved in the criminal justice system, and a significant minority are incarcerated. Individuals with CD are more likely than their peers to be dependent on benefits, to become homeless and to be hospitalized or attempt suicide. In addition, these individuals have children earlier, with more unplanned pregnancies, have more children than their peers and are more likely to display parenting problems, contributing to the intergenerational transmission of CD. CD also has a major detrimental effect on the well- being of the affected individual’s family members (not shown), with parents receiving legal sanctions or being socially excluded owing to their child’s behaviours. In addition, parents and siblings of individuals with CD are often assaulted or verbally abused in their own homes. | Fairchild, G., Hawes, D. J., Frick, P. J., Copeland, W. E., Odgers, C. L., Franke, B., … De Brito, S. A. (2019). Conduct disorder. Nature Reviews Disease Primers, 5(1), 43. https://doi.org/10.1038/s41572-019-0095-y

Diagnosis

DSM-5 diagnostic criteria for Conduct Disorder:

afp20181115p584-t1
Lillig M. (2018). Conduct Disorder: Recognition and Management. American family physician, 98(10), 584–592.

Management

CD without comorbid disorders in different developmental periods:

Management of CD without comorbid disorders in different developmental periods: Includes psychosocial family-based interventions with parents or primary caregivers for patients at all ages, but additional interventions vary according to the age of the patient, the presence or absence of the DSM-5 limited prosocial emotions (LPEs) specifier for CD (also known as callous-unemotional traits), the severity of impulsive- aggressive behaviour and the presence or absence of comorbid psychiatric disorders. | ADHD, attention-deficit/hyperactivity disorder ; ICD-11, International Classification of Diseases, 11th edition | Fairchild, G., Hawes, D. J., Frick, P. J., Copeland, W. E., Odgers, C. L., Franke, B., … De Brito, S. A. (2019). Conduct disorder. Nature Reviews Disease Primers, 5(1), 43. https://doi.org/10.1038/s41572-019-0095-y

CD with comorbid disorders:

Management of CD in those with comorbid disorders: Psychosocial family-based interventions are at the core of all interventions, but additional targeted evidence-based interventions for comorbid developmental, internalizing, or externalizing disorders should also be provided. | ADHD, attention-deficit/hyperactivity disorder; DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; ICD-11, International Classification of Diseases, 11th edition; ID, intellectual disability; ODD, oppositional defiant disorder; PTSD, post-traumatic stress disorder; SSRI, selective serotonin reuptake inhibitor | Fairchild, G., Hawes, D. J., Frick, P. J., Copeland, W. E., Odgers, C. L., Franke, B., … De Brito, S. A. (2019). Conduct disorder. Nature Reviews Disease Primers, 5(1), 43. https://doi.org/10.1038/s41572-019-0095-y

Summary:

41572_2019_100_figa_html
Fairchild, G., Hawes, D. J., Frick, P. J., Copeland, W. E., Odgers, C. L., Franke, B., … De Brito, S. A. (2019). Conduct disorder. Nature Reviews Disease Primers, 5(1), 43. https://doi.org/10.1038/s41572-019-0095-y

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