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Conduct disorder (CD) is one of the most difficult and intractable mental health problems in children and adolescents. CD involves a number of problematic behaviours, including oppositional and defiant behaviours and antisocial activities (eg, lying, stealing, running away, physical violence, sexually coercive behaviours).

This disorder is marked by chronic conflict with parents, teachers, and peers and can result in damage to property and physical injury to the patient and others. These patterns of behavior are consistent over time.

Behaviours used to classify CD fall into the 4 main categories of:

(1) aggression toward people and animals,
(2) non-aggressive destruction of property,
(3) deceitfulness, lying, and theft, and
(4) serious violations of rules.

Warning Signs of Conduct Disorders
Children may:

• lie.
• steal.
• destroy property.
• misbehave sexually.
• express their anger inappropriately.
• often break rules or laws.
• show physical and verbal aggressive behavior with other children and/or to adults.

Possible Causes of Conduct Disorders
Many factors may lead to a child developing conduct disorders, including brain damage, child abuse, defects in mental and/or emotional age-development, school failure, and negative family and/or school experiences. The child’s "bad" behavior causes a negative reaction from others, which causes the child to behave even worse.

Importance of Early Detection and Treatment
According to research, the future of children with conduct disorders tends to be very unsettled if they and their families do not receive early, ongoing and comprehensive treatment. Without treatment, these young people often are unable to adapt to the demands of adulthood and continue to have problems with relationships and employment. They generally break laws or behave antisocially.

CD usually presents initially in early or middle childhood as oppositional defiant behavior. Nearly one half of children with early oppositional defiant behavior have an affective disorder, CD, or both by adolescence. Thus, careful diagnosis to exclude irritability due to another unrecognized internalizing disorder is very important in childhood cases. Evaluation of parent-child interactions and teacher-child interactions is also critical. Even in a stable home environment, a small number of preschool-aged children display significant irritability and aggression that results in disruption severe enough to be classified as CD. The DSM-IV specifies that CD can be diagnosed in children younger than 10 years if they demonstrate even 1 of the criterion for antisocial behaviours.

CD has no lower age limit. In a child younger than 10 years, the repetitive presence of only 1 of the 15 behaviours in the DSM-IV is sufficient for the diagnosis. Thus, even a preschooler who demonstrated repetitive serious aggression, with intent to harm, meets the criteria for CD. The professional must be careful not to overuse this serious label, especially when considering young children with problematic behavior with discernible cause and with reasonable treatment potential.

Oppositional Defiant Disorder (ODD) is discriminated from CD based on the defiance of rules and argumentative verbal interactions involved in ODD; CD involves more deliberate aggression, destruction, deceit, and serious rule violations, such as staying out all night or chronic school truancy.

The DSM-IV defines the 2 major subtypes of CD as childhood-onset type and adolescent-onset type.

Childhood-onset type is defined by the presence of 1 criterion characteristic of CD before an individual is aged 10 years; these individuals are typically boys displaying high levels of aggressive behavior. These individuals often also meet criteria for attention deficit/hyperactivity disorder (ADHD). Poor peer and family relationships are present, and these problems tend to persist through adolescence into adult years. These children are more likely to develop adult antisocial personality disorder than individuals with the adolescent-onset type.

Adolescent-onset type is defined by the absence of any criterion characteristic of CD before an individual is aged 10 years. These individuals tend to be less aggressive and have more normative peer relationships. They often display their conduct behaviours in the company of a peer group engaged in these behaviours, such as a gang. These patients are less likely to fit criteria for ADHD; however, the diagnosis of ADHD is still possible. These individuals are also far less likely to develop adult antisocial personality disorder. While boys are identified more often, the estimated sex ratio of this type of CD approaches 50% for girls and boys in some communities. The prognosis for an individual with adolescent-onset type is much better than for a person with the childhood-onset type.

Treatment
Treatment is difficult because the causes of the illness are complex and each situation is unique. Also the child’s uncooperative attitude, fear, and distrust of adults adds to the challenge. CD is highly resistant to treatment. It follows a clear developmental path with indicators that can be present as early as the preschool period. Treatment is more successful when initiated early and must include medical, mental health, and educational components as well as family support.

After examining the child, a child and adolescent psychiatrist uses information from other medical specialists, as well as from the child’s family and teachers to understand the causes of the disorder and to determine a treatment plan.

Behaviour therapy and psychotherapy are usually necessary to help the child appropriately express and control anger. Remedial education may also be needed if learning disabilities are present. Treatment may also include medication in some children; such as, those with difficulty paying attention and controlling movement or those who have an associated depression.