1

Irma suwandi sadikin 130110110009 case 3 famed B4

Conduct Disorder
Children with conduct disorder are likely to demonstrate behaviors in the following four
categories: physical aggression or threats of harm to people, destruction of their own
property or that of others, theft or acts of deceit, and frequent violation of age-appropriate
rules. Conduct disorder is an enduring set of behaviors that evolves over time, usually characterized
by aggression and violation of the rights of others. Conduct disorder is associated with many other
psychiatric disorders including ADHD, depression, and learning disorders, and it is also associated with
certain psychosocial factors, such as harsh, punitive parenting, family discord,lack of appropriate
parental supervision, lack of social competence, and low socioeconomic level.
The DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders) criteria require three
specific behaviors of the 15 listed, which include bullying, threatening, or intimidating others, and
staying out at night despite parental prohibitions, beginning before 13 years of age. DSM-IV-TR also
specifies that truancy from school must begin before 13 years of age to be considered a symptom of
conduct disorder. The disorder can be diagnosed in a person older than 18 years only if the criteria for
antisocial personality disorder are not met.

Epidemiology

Occasional rule breaking and rebellious behavior is common during childhood and
adolescence, but in youth with conduct disorder, behaviors that violate the rights of others are
repetitive and pervasive. Estimated rates of conduct disorder among the general population range
from 1 to 10 percent, with a general population rate of approximately 5 percent. The disorder is
more common among boys than girls, and the ratio ranges from 4 to 1 to as much as 12 to 1.
Conduct disorder occurs with greater frequency in the children of parents with antisocial personality
disorder and alcohol dependence than in the general population. The prevalence of conduct disorder
and antisocial behavior is associated with socioeconomic factors.

Etiology

No single factor can fully account for a child's antisocial behavior and conduct disorder. Rather,
many biopsychosocial factors contribute to development of the disorder.
1. Parental Factors
Harsh, punitive parenting characterized by severe physical and verbal aggression is associated
with the development of children's maladaptive aggressive behaviors. Chaotic home conditions are
associated with conduct disorder and delinquency. Divorce itself is considered a risk factor, but the
persistence of hostility, resentment, and bitterness between divorced parents may be the more
important contributor to maladaptive behavior. Parental psychopathology, child abuse, and negligence
often contribute to conduct disorder. Sociopathy, alcohol dependence, and substance abuse in the
parents are associated with conduct disorder in their children. Parents may be so negligent that a
child's care is shared by relatives or assumed by foster parents. Many such parents were scarred by
their own upbringing and tend to be abusive, negligent, or engrossed in getting their own personal
needs met.
2. Sociocultural Factors
Socioeconomically deprived children are at higher risk for the development of conduct
disorder, as are children and adolescents who grow up in urban environments. Unemployed parents,
lack of a supportive social network, and lack of positive participation in community activities seem to
predict conduct disorder. Associated findings that may influence the development of conduct disorder
in urban areas are increased rates and prevalence of substance use. A recent survey of alcohol use
and mental health in adolescents found that weekly alcohol use among adolescents is associated with
increased delinquent and aggressive behavior. Significant interactions between frequent alcohol use
and age indicated that those adolescents with weekly alcohol use at younger ages were most likely to
exhibit aggressive behaviors and mood disorders. Although drug and alcohol use does not cause
conduct disorder, it increases the risks associated with it.
3. Psychological Factors

Irma suwandi sadikin 130110110009 case 3 famed B4

Children brought up in chaotic, negligent conditions often express poor modulation of
emotions, including anger, frustration, and sadness. Poor modeling of impulse control and the chronic
lack of having their own needs met leads to a less well-developed sense of empathy.
4. Neurobiological Factors
Neurobiological factors in conduct disorder have been little studied, but research in ADHD
yields some important findings, and this disorder often coexists with conduct disorder. In some children
with conduct disorder, a low level of plasma dopamine -hydroxylase, an enzyme that
converts dopamine to norepinephrine, has been found. This finding supports a theory of
decreased noradrenergic functioning in conduct disorder. Some conduct-disordered juvenile
offenders have high serotonin levels in blood. Evidence indicates that blood serotonin levels
correlate inversely with levels of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the
cerebrospinal fluid (CSF) and that low 5-HIAA levels in CSF correlates with aggression and violence.
5. Neurologic Factors
A recent Canadian study investigated the relationship between resting frontal brain electrical
activity (EEG), emotional intelligence, and aggression and rule breaking in 10-year-old children. Frontal
resting brain electrical activity has been hypothesized to reflect the ability to regulate emotionality.
Results of this study indicate that children with higher reported externalizing behaviors had
significantly greater relative right frontal EEG activity during rest compared with children with little or
no reported aggressive behavior. Boys tended to show lower emotional intelligence than girls and
greater aggressive behavior than girls.
6. Child Abuse and Maltreatment
It is widely accepted that children chronically exposed to violence, especially those receiving
repeated physical or sexual abuse that starts at a young age are at high risk for behaving aggressively.
Children who are exposed to caregivers who are exposed to violence are also likely to demonstrate
disruptive and aggressive behaviors themselves. A recent study of female caregivers' exposed to
intimate partner violence revealed a strong association with offspring aggression and mood
disturbance.
7. Comorbid Factors
ADHD, CNS dysfunction or damage, and early extremes of temperament can predispose a child
to conduct disorder. Propensity to violence correlates with CNS dysfunction and signs of severe
psychopathology, such as delusional tendencies.

Diagnosis and Clinical Features

Conduct disorder does not develop overnight,instead, many symptoms evolve over time until a
consistent pattern develops that involves violating the rights of others. Very young children are
unlikely to meet the criteria for the disorder, because they are not developmentally able to exhibit the
symptoms typical of older children with conduct disorder. A 3-year-old does not break into someone's
home, steal with confrontation, force someone into sexual activity, or deliberately use a weapon that
can cause serious harm. School-age children, however, can become bullies, initiate physical fights,
destroy property, or set fires. The DSM-IV-TR diagnostic criteria for conduct disorder are given in Table
44-2.

The average age of onset of conduct disorder is younger in boys than in girls. Boys most
commonly meet the diagnostic criteria by 10 to 12 years of age, whereas girls often reach 14
to 16 years of age before the criteria are met.
Children who meet the criteria for conduct disorder express their overt aggressive behavior in
various forms. Aggressive antisocial behavior can take the form of bullying, physical
aggression, and cruel behavior toward peers.
Children may be hostile, verbally abusive, impudent, defiant, and negativistic toward adults.
Persistent lying, frequent truancy, and vandalism are common.
In severe cases, destructiveness, stealing, and physical violence often occur. Some adolescents
with conduct disorder make little attempt to conceal their antisocial behavior.

Irma suwandi sadikin 130110110009 case 3 famed B4

Sexual behavior and regular use of tobacco, liquor, or nonprescribed psychoactive substances
begin unusually early for such children and adolescents. Suicidal thoughts, gestures, and acts
are frequent in children and adolescents with conduct disorder who are in conflict with peers,
family members, or the law and are unable to problem solve their difficulties.
Some children with aggressive behavioral patterns have impaired social attachments, as
evinced by their difficulties with peer relationships. Some may befriend a much older or
younger person or have superficial relationships with other antisocial youngsters.
Many children with conduct problems have poor self-esteem, although they may project an
image of toughness. They may lack the skills to communicate in socially acceptable ways and
appear to have little regard for the feelings, wishes, and welfare of others.
Children and adolescents with conduct disorders often feel guilt or remorse for some of their
behaviors, but try to blame others to stay out of trouble.
Many children and adolescents with conduct disorder suffer from the deprivation of having few
of their dependency needs met and may have had either overly harsh parenting or a lack of
appropriate supervision.
The deficient socialization of many children and adolescents with conduct disorder can be
expressed in physical violation of others and, for some, in sexual violation of others.
Severe punishments for behavior in children with conduct disorder almost invariably increases
their maladaptive expression of rage and frustration rather than ameliorating the problem.
Table 44-2 DSM-IV-TR Diagnostic Criteria for Conduct Disorder

A.

A repetitive and persistent pattern of behavior in which the basic rights of others or major ageappropriate societal norms or rules are violated, as manifested by the presence of three (or
more) of the following criteria in the past 12 months, with at least one criterion present in the
past 6 months:
Aggression to people and animals
1.

often bullies, threatens, or intimidates others

2.

often initiates physical fights

3.

has used a weapon that can cause serious physical harm to others (e.g., a bat, brick,
broken bottle, knife, gun)

4.

has been physically cruel to people

5.

has been physically cruel to animals

6.

has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed
robbery)

7.

has forced someone into sexual activity

Destruction of property
1.

has deliberately engaged in fire setting with the intention of causing serious damage

2.

has deliberately destroyed others' property (other than by fire setting)

Deceitfulness or theft
1.

has broken into someone else's house, building, or car

2.

often lies to obtain goods or favors or to avoid obligations (i.e., consothers)

3.

has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but

Irma suwandi sadikin 130110110009 case 3 famed B4

without breaking and entering; forgery)

Serious violations of rules
1.

often stays out at night despite parental prohibitions, beginning before age 13 years

2.

has run away from home overnight at least twice while living in parental or parental
surrogate home (or once without returning for a lengthy period)

3.

is often truant from school, beginning before age 13 years

The disturbance in behavior causes clinically significant impairment in social, academic, or

occupational functioning.

If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Code based on age at onset:

Conduct disorder, childhood-onset type: onset of at least one criterion characteristic of conduct
disorder prior to age 10 years
Conduct disorder, adolescent-onset type: absence of any criteria characteristic of conduct
disorder prior to age 10 years
Conduct disorder, unspecified onset: age at onset is not known
Specify severity:
Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct
problems cause only minor harm to others
Moderate: number of conduct problems and effect on others intermediate between mild
and severe
Severe: many conduct problems in excess of those required to make the diagnosis or conduct
problems cause considerable harm to others
(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed.
Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)
In other cases, conduct disorder includes repeated truancy, vandalism, and serious physical
aggression or assault against others by a gang, such as mugging, gang fighting, and beating. Children
who become part of a gang usually have the skills for age-appropriate friendships. They are likely to
show concern for the welfare of their friends or their own gang members and are unlikely to blame
them or inform on them. In most cases, gang members have a history of adequate or even excessive
conformity during early childhood that ended when the youngster became a member of the delinquent
peer group, usually in preadolescence or during adolescence. Also present in the history is some
evidence of early problems, such as marginal or poor school performance, mild behavior problems,
anxiety, and depressive symptoms. Some family social or psychological pathology is usually evident.

Violent Video Games and Violent Behavior

Over the last few decades violent video games have become ubiquitous in western societies,
especially as frequent activities for child and adolescent males. A recent review of the literature of the
effect of violent video games on children and adolescents revealed that violent video game playing is
related to aggressive affect, physiologic arousal, and aggressive behaviors. It stands to reason that the
degree of exposure to violent games and the more restriction of activity would be related to a greater
preoccupation with violent themes.

Pathology and Laboratory Examination

No specific laboratory test or neurological pathology helps make the diagnosis of conduct
disorder. Some evidence indicates that amounts of certain neurotransmitters, such as serotonin in the

Irma suwandi sadikin 130110110009 case 3 famed B4

CNS, are low in some persons with a history of violent or aggressive behavior toward others or
themselves. Whether this association is related to the cause, or is the effect, of violence or is unrelated
to the violence is not clear.

Primary source : Kaplan & Sadocks Synopsis of Psychiatry 10th edition