Conduct Disorder in Children

Antisocial personality disorder (ASPD) — a psychological condition characterized by a lack of empathy and a remorseless disregard for and violation of the rights of others — is only diagnosed in people 18 and over.

Symptoms of ASPD begin in childhood or adolescence, but when children show serious signs of antisocial behavior, they are diagnosed instead with conduct disorder. While not all children with conduct disorder end up developing antisocial personality disorder, “all adults with ASPD first show signs of psychopathy during childhood,” explains Kalina J. Michalska, PhD, an assistant professor of psychiatry at the University of California in Riverside who studies children with this issue.

That said, conduct disorder (CD) is hard to quantify, with difficult-to-identify causes. (1) “The disorder arises from the poorly understood interaction of neurobiological, genetic, environmental, and social-developmental factors, as well as adverse childhood experiences, which may negatively influence a growing child’s capacity for empathy and moral development,” says James B. McCarthy, PhD, an associate professor of psychology at Pace University in New York City.

In the United States, researchers estimate that conduct disorder affects about 2 to 10 percent of the population, with a higher rate for boys. (2,3While some children with conduct disorder go on to develop ASPD in adulthood — maybe in the range of 30 to 40 percent, says Dr. Michalska — most don’t.

What Are the Signs of Conduct Disorder?

The criteria experts use to determine if a child or adolescent has conduct disorder fall into the categories below. For a diagnosis to be made, says Michalska, a child should have exhibited several of these behaviors over the previous year, with at least one in the most recent six months. “When we see kids with more than three of these behaviors, that’s a really big red flag.”

  • Aggression Toward People and Animals This includes bullying, threatening or attempting to intimidate others, forcing sexual activity, initiating physical fights, and using weapons. Cruelty to animals, notes Michalska, doesn’t mean “normal” behavior like cutting an earthworm in half to see how it works. “This is really disturbing stuff like cutting off a kitten’s tail,” she says. 
  • Destruction of Property The child breaks or damages others’ property on purpose, or intentionally sets fires — not for fun (such as a bonfire), but to cause damage. 
  • Deceitfulness, Lying, and Stealing Breaking into a home, building, or car; lying to avoid trouble or obligations; shoplifting
  • Serious Rule Violations This includes actions such as staying out at night without permission or against parental wishes, running away repeatedly, and school truancy that goes beyond occasionally skipping classes.

In a recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an additional “specifier” was added to bring more clarity to a diagnosis of CD. “It’s ‘conduct disorder with limited prosocial emotions,’” explains Michalska, defined as displaying a lack of remorse or guilt; callousness and lack of concern; and shallow emotions.

“When you have limited prosocial emotion, you might see a child starting a fight or hurting an animal, and not caring about the effects of their actions, not feeling remorse.” That helps separate the children with more serious or intractable CD from those who, say, exhibit bad behavior because they can’t control themselves, but then get very upset about it afterward, Michalska explains.

How Is Conduct Disorder in Children Treated?

The most important factor in treating children with conduct disorders is whole-family involvement, says Dr. McCarthy. “If parents and other important adult figures are emotionally present, caring, responsible, and appropriately authoritative, and if they serve as role models to demonstrate sensitivity, compassion, and moral behavior,” positive outcomes in treatment are possible.

But it’s not simple, in part because many children with this and related disorders often live in the kind of family environment that works against or worsens their problems, he adds. 

Here’s a look at treatment approaches for CD:

  • What Doesn’t Work: Punishment Children with conduct disorder tend to be punishment-insensitive; it just isn’t effective because they may lack the ability to feel remorse, says Michalska.
  • What Can Work: Multisystemic Therapy This is an intensive treatment that requires the cooperation of the entire family. It generally involves therapists working closely with the child and family to change problematic aspects of the child’s environment, such as chaos and disorganization. “We may look at certain aspects of the environment and try to substitute things that are more appropriate," says Michalska. A number of studies have shown that it can be effective. (4)
  • What May Work: Medication“Sometimes stimulant drugs, like those used to treat ADHD, look as though they’re effective,” says Michalska, but that may be because ADHD is often comorbid with CD. About 16 to 20 percent of children with conduct disorder also have ADHD. (2)

When to Worry About Conduct Disorder

As serious and scary as the signs and symptoms of CD clearly are, it’s important to remember that many children simply grow out of these kinds of behaviors. But there’s still a cause for concern, says Michalska, particularly if the most serious symptoms arise in children prior to age 7 or 8, because that may indicate intractability . “If you see CD traits in early childhood, that usually leads to more chronic, more persistent, long-term problems,” she says.

If parents or other adults see reason for concern about children engaging in these behaviors and displaying a lack of empathy or remorse, “consulting with a qualified, well-trained mental health professional with experience working with at-risk youth is the first and most important step,” says McCarthy.

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