Every parent knows that children don’t always behave the way they want them to. That’s part of parenting: teaching kids right from wrong, teaching them the difference between appropriate behavior from inappropriate behavior, and teaching them how to get along with others. When our kids are toddlers, we excuse almost everything, because we know our kids know almost nothing: they need to be taught.
Learning these basics is also part – if not most – of growing up.
When you’re a little kid all you can think about is yourself, what you want, and how you’re going to get it. You go to extremes – like throwing tantrums or engaging in defiant behavior – to get what you think should be yours. Gradually you learn displaying big emotion is not the best way to achieve your goals. Over time, you learn that defiance and disobedience does not help you achieve your goals, either.
However, some children develop what’s known as conduct disorder (CD), which is classified by the Diagnostic and Statistical Manual of Mental Disorders – Volume 5 (DSM-V) as a behavioral disorder, along with disorders such as disruptive mood dysregulation disorder (DMDD), oppositional-defiant disorder (ODD), and intermittent explosive disorder.
This article will address the prevalence of conduct disorder among children and teens in the U.S., offer signs and symptoms of conduct disorder, and discuss the best treatment options for adolescents with conduct disorder, which may include outpatient treatment, inpatient treatment, or residential treatment.
What is Conduct Disorder and How Often Does it Occur?
The DSM-V identifies two major types of conduct disorder, related to the age of onset:
- Child/early onset conduct disorder appears in children before age 10.
- Adolescent onset conduct disorder appears after age ten and before age 18.
Statistics show the following prevalence of conduct disorder among children and teens:
- Early onset conduct disorder: 2%-5% of children in the U.S. develop early onset conduct disorder
- Adolescent onset conduct disorder: 5%-9% of adolescents in the U.S. develop adolescent onset conduct disorder
In addition, statistics show that conduct disorder is more common among boys than among girls:
- Boys: 6%-16% of boys in the U.S. develop conduct disorder
- Girls: 2%-9% of girls in the U.S. develop conduct disorder
Here are the criteria established by the DSM-V for a conduct disorder diagnosis.
Conduct Disorder (CD)
Conduct Disorder (CD) is the repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:
- Aggression to People and Animals
- Often bullies, threatens, or intimidates others.
- Often initiates physical fights.
- Has used a weapon that can cause serious physical harm to others
- Has been physically cruel to people
- Engaged in physical cruelty to animals
- Has stolen while confronting a victim
- Has forced someone into sexual activity.
- Destruction of Property
- Has deliberately engaged in fire setting with the intention of causing serious damage.
- Has deliberately destroyed others’ property
- Deceitfulness or Theft
- Has broken into someone else’s house, building, or car.
- Often lies to obtain goods or favors or to avoid obligations
- Has stolen items of nontrivial value without confronting a victim
- Serious Violations of Rules
- Often stays out at night despite parental prohibitions, beginning before age 13 years.
- Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.
- Is often truant from school, beginning before age 13 years.
- The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
A diagnosis of conduct disorder requires a clinician to identify one of three types of severity:
Problems beyond those required to meet the basic diagnosis are minor.
This designation exists for individuals with behavioral problems that fall between mild and severe.
Problems beyond those required to make the diagnosis are present, significant, and/or cause considerable harm to others
In addition, a diagnosis of conduct disorder requires a clinician to specify whether the child or teen has conduct disorder with limited prosocial emotions. This requires the persistent presence of the following characteristics over at least a year and represents the child or teen’s typical pattern of social and emotional functioning, rather than occasional displays in some situations. The limited prosocial emotions category requires at least two of the following behaviors over a year across multiple setting and types of relationships:
Lack of remorse or guilt.
The child or teen does not feel bad when engaging in negative behavior, and shows an absence of concern for the negative impact of their actions on others. For example, a child or teen does not feel remorse for breaking a rule or hurting another person.
Lack of empathy.
The child or teen is often described by adults or peers as cold or uncaring, and disregards or is unconcerned about the feelings of others.
Unconcerned about performance.
The child or teen does not worry about inadequate performance or disruptive behavior at school, home, or in other situations. They make no attempt to improve performance, and often place blame for their poor performance on others.
Shallow or deficient affect.
The child or teen does not express, share, or show emotions to others. When they do, they appear insincere, and often appear as if they’re only displayed to intimidate or manipulate others.
[Note: In the behavioral health context, affect means someone’s mood, or how someone appears or the impression they give others, emotionally]
Those are all the clinical criteria required to meet a diagnosis for conduct disorder. If your child or teen displays any of these behavioral signs, then it’s important to arrange for a full biopsychosocial assessment from a mental health professional at a behavioral health treatment center for teens. In some cases, a teen with conduct disorder may require outpatient or intensive outpatient treatment (IOP). In more severe cases, a teen may need inpatient treatment for conduct disorder, provided at a residential treatment center for teens (RTC).
Conduct Disorder and Co-Occurring Disorders
Before we discuss what kinds of treatment work best for children or teens with conduct disorder, we should mention that conduct disorder often develops alongside, before, or after another behavioral or mental health disorder. When CD appears with another disorder, they’re called co-occurring disorders. Disorders that commonly co-occur with CD include:
- Attention-deficit hyperactivity disorder (ADHD)
- Posttraumatic stress disorder (PTSD)
- Oppositional defiant disorder (ODD)
- Substance use disorders
A teen with CD may or may not develop one of the disorders listed above, and vice-versa. However, the presence of these disorders increases the risk of developing conduct disorder, and vice-versa. Risk factors for conduct disorder include:
- Childhood or adolescent abuse or neglect
- Childhood or adolescent trauma
- Genetic predisposition
- A traumatic brain injury
The presence of these experiences or factors does not mean a child or teen will develop conduct disorder. However, the presence of the experiences or factors increases the chance that a child or teen will develop conduct disorder.
Evidence-Based Treatment for Conduct Disorder
When seeking treatment for a child or teen with conduct disorder, it’s critical to receive an accurate diagnosis from a licensed mental health professional. An accurate diagnosis for conduct disorder requires input from various sources across different aspects of the child or teen’s life. Teachers, peers, friends, relatives, school administrators, and coaches – anyone who has had direct and extended contact with the child or teen – can help verify the severity of the conduct disorder. This will, in turn, help parents and mental health professionals collaborate on the right type and level of care for a teen diagnosed with conduct disorder.
Inpatient treatment for conduct disorder – which may be appropriate for all conduct disorder diagnoses, including mild, moderate, and severe – involves the child or teen living at the treatment facility with 24/7 support, supervision, and monitoring. When a child or teen with conduct disorder poses a danger or threat to the people around them – including family, peers, and teachers – then a mental health professional may recommend inpatient treatment.
However, treatment for conduct disorder at any level of care – outpatient, inpatient, or residential – is based on a combination of psychotherapy (talk therapy) and behavioral therapy. Medication is rarely used to treat conduct disorder, but when co-occurring disorders are present, medication may be necessary.
The types of talk-therapy that work best for conduct disorder include:
A specific type of family therapy called functional family therapy is often recommended for children or teens with conduct disorder. It’s designed for children or adolescents who frequently act out, and prioritizes:
- Reducing negativity in the home
- Improving communication between family members
- Increasing support between family members
Parent Management Training
This type of therapy focuses on teaching parents the skills necessary to manage the behavior of a defiant child or teen. It prioritizes:
- Improving the quality of parent-child interactions
- Coaching parents on how to communicate with defiant or oppositional children in order to increase the likelihood of a positive, prosocial response
- Improving parental ability to monitor and supervise children
- Teaching parents effective disciplinary strategies (i.e. authoritative as opposed to authoritarian or neglectful)
CBT focuses on helping teens identify and change negative thought patterns, self-talk, and beliefs and replace them with productive, prosocial thoughts and beliefs. CBT skills training helps children and teens:
- Reduce angry, impulsive responses
- Overcome deficits in social cognition associated with conduct disorder
- Apply productive, prosocial problem solving skills
- Develop fundamental social skills
This is an intensive, comprehensive approach that involves both the family and the community. It’s often used when children or teens with conduct disorder get in legal trouble or engage in behavior that results in involvement with the juvenile justice system. It helps these teens by addressing environmental factors such home/family life, teachers, peers, and neighborhood influences that may contribute to the negative behaviors associated with conduct disorder.
If you’re the parent of a child or teen with conduct disorder, we understand it’s not easy. It’s crucial for you to know that professional treatment and support can make a dramatic difference in the behavior of your teen.
It’s critical to get your child or teen professional support as soon as possible.
Evidence shows that early onset conduct disorder – which we call child onset, above – often leads to severe mental health and emotional problems during adulthood, including antisocial personality disorder (ASPD). On the other hand, late, or adolescent onset conduct disorder – when treated – does not correlate as strongly with adult mental health disorders like ASPD as child onset conduct disorder. Teens who develop conduct disorder later in adolescence typically respond positively to treatment, and experience more favorable outcomes, in general, than children who develop conduct disorder before the age of ten.
Commit to Therapy, Treatment, and Support
We won’t pull punches, here. Treatment for conduct disorder is not simple. The American Academy of Child & Adolescent Psychiatry describes the situation like this:
“Treatment of children with conduct disorder can be complex and challenging. Adding to the challenge of treatment are the child’s uncooperative attitude, fear, and distrust of adults. In developing a comprehensive treatment plan, [clinicans] may use information from the child, family, teachers, community (including the legal system) and other medical specialties to understand the causes of the disorder.”
Something we advise parents frequently, for all types of mental health and/or behavioral disorders, is this: the earlier a disorder is diagnosed, and the sooner treatment begins, the more likely the chance of long-term treatment success.
This is particularly true for teens with conduct disorder. Teens who display extreme, aggressive behavior that’s dangerous to those around them may require inpatient treatment – but not all teens will require inpatient treatment for conduct disorder. Conduct disorder that’s left untreated often escalates to greater problems. However, all parents should know and find hope in the fact that with early, effective, evidence-based treatment, conduct disorder is a manageable condition.