Conduct Disorder DSM-5 312.81 (F91.1), 312.82 (F91.2), and 312.89 (F91.9)

Conduct Disorder DSM-5 312.81 (F91.1), 312.82 (F91.2), and 312.89 (F91.9)

DSM-5 Category: Disruptive, Impulse-Control, and Conduct Disorders

Introduction

CD (Conduct Disorder) is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis typically assigned to individuals under age 18, who habitually violate the rights of others, and will not conform their behavior to the law or social norms appropriate for their age. Conduct Disorder may also be described as juvenile delinquency; behavior patterns which will bring a young person into contact with the juvenile justice system, or other disciplinary action from parents or administrative discipline from schools. It is well established that Conduct Disorder can be a premorbid condition for APD (Antisocial Personality Disorder) or habitual adult criminality, especially when CU (Callous-Unemotional) traits are present. There is well established co-morbidity and premorbidity with ADD/ADHD (Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder) and ODD (Oppositional Defiant Disorder) (Pardini & Fite, 2010). The direction of causality may be bi-directional, as ADD/ADHD children are at risk for maltreatment from peers and parents, and maltreatment is established as a risk factor for both Conduct Disorder and adult criminality (De Sanctis, Nomura, Newcorn, & Halperinb, 2012). It has been found that the rate of Conduct Disorder resulting in adult criminality is as high as 50% (Bonin, Stevens, Beecham, Byford, & Parsonage, 2011).

Symptoms of Conduct Disorder

According to the DSM-5, to diagnose Conduct Disorder, least four of the following have to be present

  • Aggressive behavior toward others and animals.
  • Frequent physical altercations with others.
  • Use of a weapon to harm others.
  • Deliberately physically cruel to other people.
  • Deliberately physically cruel to animals.
  • Involvement in confrontational economic order crime- e.g., mugging.
  • Has perpetrated a forcible sex act on another.
  • Property destruction by arson.
  • Property destruction by other means.
  • Has engaged in non-confrontational economic order crime- e.g., breaking and entering.
  • Has engaged in non-confrontational retail theft, e.g., shoplifting.
  • Disregarded parent's curfew prior to age 13.
  • Has run away from home at least two times.
  • Has been truant before age 13.

The preceding criteria is accompanied by the following:

1. The behaviors cause significant impairment in functioning and

2. If the individual over age 18 the criteria for APD is not met.

Further qualifiers are:

1. Child, Adolescent, or Unspecified onset.

2 Limited prosocial emotions, - lack of remorse or guilt, lack of empathy, callousness, unconcerned about performance, shallow or deficient affect

3. With mild, moderate, or severe levels of severity (American Psychiatric Association, 2013).

Onset

The DSM-5 notes that Conduct Disorder can appear as early as the preschool years, with ODD (Oppositional Defiant Disorder) a common premorbid condition, which may progress to Conduct Disorder. Middle childhood to middle adolescence is the time frame where Conduct Disorder symptoms are most apparent,and come to parental/educational/clinical attention. Rejection by more prosocial peers and association with delinquent peers with reinforcement of conduct disordered behaviors my occur (American Psychiatric Association, 2013).

Prevalence

According to the DSM-5, the annual prevalence of Conduct Disorder is 2% to 10%, with a median of 4%. It is more common in boys,or at least more apparent and more frequently diagnosed, due to boy's tendency to act out violently, while girls tend to act out in interpersonal relationships- .eg., social rejection of disliked peers, non-confrontation of a victim through malicious postings on a social networking site(American Psychiatric Association, 2013).

Risk Factors

The DSM-5 indicates that risk factors for Conduct Disorder are under controlled temperament, low verbal IQ, parental rejection and neglect, other forms of child maltreatment, including sexual abuse, and inconsistent parenting. There are numerous other risk factors that have been identified. A parental history of ADD/ADHD and conduct disorder is also identified as a risk factor (American Psychiatric Association, 2013), as is parental drug and alcohol abuse and dependence (Haber, Bucholz, Jacob, Grant, Scherrer, Sartor, Duncan, & Heath, 2010). Parental overindulgence has also been increasingly identified as a risk factor due to the development of a sense of entitlement, lack of concern for others, self absorption unrealistic expectations, and frustration when these expectations are not delivered (Fogarty, 2009). Neurological malfunction in the amygdala and the orbito-frontal cortex are implicated in the clinical manifestations of Conduct Disorder. The inability to self regulate combined with a more activated fear/anger center is an alignment for the production of dysregulated behavior (Finger, Marsh, Blair, Reid, Sims, Ng, Pine, & Blair, 2011). Lack of economic opportunity is frequently cited in the criminal justice literature as a cause of delinquency, as well as parental criminality, and youths having unoccupied/unsupervised time. However, neo- classical criminology theorist Samenow (2004) argues that many youths grow up under adverse circumstances, and do not engage in delinquent/Conduct Disordered behavior, but make more pro-social choices despite adversity. Delinquency is therefore a rational, though maladaptive and dysfunctional choice, arrived at through active rejection of education, parental/societal values, and legitimate employment opportunities (Samenow, 2004).

Comorbidity

The DSM-5 indicates that CD is comorbid with ADD/ADHD, and substance use disorders. (American Psychiatric Association, 2013).

Treatment of Conduct Disorder

The DSM-5 does not specify treatment options for APD (American Psychiatric Association, 2013). It is noted that evidence based parenting programs for parents of children with CD offered in the UK reduced the incidence of Conduct Disorder progressing to adult criminality (Bonin, Stevens, Beecham, Byford, Parsonage, 2011). Substance abuse treatment may be indicated, as comorbidity is noted between Conduct Disorder and substance abuse disorders. As Conduct disordered behavior will typically result in contact with the Juvenile Justice system, treatment in participation may be mandated and enforced, or occur in an institutional setting, or academic programs for behaviorally disturbed youths. Supervision, clear expectations for behavior, accountability, and consequences for inappropriate behavior are all part of a quality treatment program.

Impact on Functioning

ADP will typically have strong impacts on most areas of functioning. STI's, (Sexually Transmitted Infections) unwanted pregnancy, juvenile justice system involvement, family strife, and injuries from accidents or fighting are all noted in the DSM-5 and other sources (American Psychiatric Association, 2013; Bonin, et al 2011). Conduct disordered behavior in teens can have a profound impact on parents, including self-blame of their child’s/ teens condition, guilt, shame, anxiety, social embarrassment, financial problems, conflicts within the family, interruption of work, and fatigue (Meltzer, Ford, Goodman, & Vostanis, 2011).

Differential Diagnosis

There are diagnostic rule-outs for the clinician to consider. In the DSM -5, disorders such as

ODD (Oppositional Defiant Disorder) ADD/ADHD, (Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder) bipolar disorder, adjustment disorder, IED (Intermittent Explosive Disorder), and substance use disorders are recommended rule-outs (American Psychiatric Association, 2013). ODD will is typically diagnosed in younger children, and involves a pattern of acting out and rebelliousness toward adults, refusal to follow directives from elders, and deliberate efforts to annoy adults. ADD/ADHD will involve inability to maintain attention and focus, or if the hyper-kinetic component is present, inability to sit in one place, or contain behavior. The person with ADD/ADHD may desire to conform their behavior to parental directives, or societal norms, but be unable to, but do not have malicious intent toward others. The manic phase of Bi-polar disorder may involve reckless and impulsive behavior, but the etiology and course are very different than Conduct Disorder. Adjustment disorders tend to be traceable to a specific stressor or series of stressors, and tend to resolve over time, IED involves discrete period of explosive anger and acting out, but may be accompanied by remorse and regret after the outburst. Behavior while under the influence of drugs or alcohol will be altered, and drug seeking behavior will typically progress to abandoning moral standards. There is a high comorbidity with Conduct Disorder and substance abuse disorders, but they are discrete diagnoses (American Psychiatric Association, 2013).

References:

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

Bonin, E.M., Stevens, M., Beecham,J., Byford,S., Parsonage, M. (2011); Costs and longer-term savings of parenting programmes for the prevention of persistent conduct disorder: A modelling study. BioMed Central Public Health. 11:803. doi:10.1186/1471 2458-11-803 PMCID: PMC3209459

De Sanctis, V.A. Nomura, Y, Newcorn, J. H., and Halperinb. J.M, (2012). Childhood maltreatment and conduct disorder: Independent predictors of criminal outcomes in ADHD youth Child Abuse and Neglect 36(0): 782–789. doi: 10.1016/j.chiabu. 2012.08.003 PMCID: PMC3514569 NIHMSID: NIHMS422057

Fogarty, J. (2009). Overindulged Children and Conduct Disorder: Treating Overindulgent Families. Cross Country Education. Holiday Inn, South Burlington VT.

Samenow, S.E. ( 2004). Inside the Criminal Mind. (2), Crown: New York.


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