If the individual is age 18 years or older, criteria are not met for antisocial personality disorder. With limited prosocial emotions: To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at least 12 months and in multiple relationships and settings. These characteristics reflect the individual's typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations.
Thus, to assess the criteria for the specifier, multiple information sources are necessary. In addition to the individual's self-report, it is necessary to consider reports by others who have known the individual for extended periods of time e. The individual shows a general lack of concern about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules.
Callous—lack of empathy: Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring. The person appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others, even when they result in substantial harm to others. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for his or her poor performance.
Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial e.
Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others e.
Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others e. Reprinted with permission from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Risk factors for developing conduct disorder include male sex, maternal smoking during pregnancy, living in poverty in childhood, and parental conditions such as substance use disorders and criminal behavior.
Additional risk factors are exposure to physical or sexual abuse in childhood, or to domestic violence between parents. Family instability, specifically changes in parent or guardian figures, is a risk factor, as are lower cognitive ability and association with peers who use substances, are truant from school, or engage in criminal activity.
For a formal diagnosis, the DSM-5 specifies that at least three of 15 criteria should have been present in the past 12 months, with at least one criterion present in the past six months. The Vanderbilt scales are available on several websites, such as www. The Vanderbilt scales also include screening questions for disorders such as conduct disorder and oppositional defiant disorder ODD. Physical findings during the visit and laboratory testing do not contribute to the diagnosis, although evidence of injuries may prompt a revelation of pertinent information, such as fighting.
The following cases illustrate ways that conduct disorder may present in a family medicine setting. Such cases should prompt the health care professional to ask additional follow-up questions Table 2. Have you ever skipped school? If so, how often? Under what circumstances? Have you been suspended or expelled from school? If so, what were the situations around that? Have you ever gotten into any physical fights at school?
What led up to those fights? Have you gotten into physical fights in your neighborhood, or other places? Have you gotten in trouble with the police? If so, were you arrested? Have there been any charges filed against you? If so, for what? Have you had other interactions with the police that did not lead to an arrest? If so, what happened? Have you engaged in any stealing?
Have you been in situations where you destroyed property? If so, what were the circumstances? Have you experimented with fire, or set any fires? If so, what was the situation? Have there been times when you stayed out very late without permission? Have you stayed out all night? Have there been times when you have run away from home? Note: In assessing the answers to these questions, the family physician should prioritize safety. If the youth indicates that he or she is in imminent danger of harming others or of being harmed e.
If the youth answers yes to ANY of the above questions, the family physician should try to engage the youth around possible reasons to change behavior, discuss the concern with parents, and encourage ongoing communication within the family and with other health professionals.
Not all of the above questions may be age-appropriate. The physician should choose which questions to ask based on age and context. Conduct disorder: diagnosis and treatment in primary care. Am Fam Physician.
A seven-year-old boy presents for a well-child visit. He walks around the office, occasionally picking up objects or opening drawers, as his mother describes his recent suspension from school for pushing other children. The boy threatened to stab another child, stole items from classmates' lunches, and is suspected of stealing money from the teacher's purse.
He once left the school premises without permission, prompting a call to police. At home, he often fights with siblings and has thrown rocks at other children. He seems to barely pay attention to the telling of his history and does not contradict any of his mother's statements. His mother reports feeling overwhelmed because of his behaviors and mentions that his father is incarcerated. She states that her relatives are taking turns coming to the home and are trying to help her control his behaviors.
A year-old girl presents at the end of the summer for a required school physical. She becomes irritated as her mother tearfully relates that her daughter has been smoking tobacco and marijuana cigarettes and has left home overnight on several occasions. This summer she was arrested for shoplifting clothes and jewelry and was also charged with marijuana possession.
As her mother mentions that her daughter received probation, the girl retorts that if her mother had money to buy clothes she would not have to steal them. The girl adds that her mother is jealous because she has friends, but her mother spends her time alone. The differential diagnosis of conduct disorder includes screening for other disorders in which aggression or disruptive behaviors may be present Table 3 , 1 such as ODD, ADHD, mood disorders, and adjustment disorders.
There is a pattern of opposition and defiance to adults, but no pattern of violation of the rights of others, aggression, property destruction, or deceitfulness or theft. Although there may be aggression, it is impulsive rather than planned or predatory.
There may be aggression, but it is impulsive, and there may be intrusiveness and hyperactivity, but there is no pattern of violation of the rights of others. There may be aggression as part of temper outbursts, but unlike conduct disorder, the primary pattern is of irritability and temper outbursts, whether or not aggression is involved, rather than violation of the rights of others. The primary symptom is typically depressed mood, and there may be changes in sleep, appetite, and energy level, as well as suicidal ideation.
These disorders do not involve aggression, property destruction, or deceitfulness or theft. In addition to grandiosity there may be periods of impulsivity, but this occurs as part of a manic episode rather than a persistent pattern. Adjustment disorders with depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct.
There may be irritability and disruptive behaviors, but these occur in response to a stressor and typically resolve within six months of elimination of the stressor. There may be disruptive behaviors in the context of intoxication or withdrawal, but the disruptive behaviors should resolve in the absence of these conditions.
The primary symptom is typically reexperiencing trauma in the form of nightmares or intrusive memories. There are efforts to avoid reminders of the trauma. There may be irritability and outbursts. Unlike conduct disorder, there is no pattern of violation of the rights of others, property destruction, or deceitfulness or theft. Information from reference 1. Treatment for conduct disorder is multifaceted and involves treatment of comorbidities, family support, psychosocial interventions, and pharmacotherapy for some patients Table 4.
Advise parents to treat their own physical and mental health issues, if applicable. Demonstrate listening and communicating skills to parents and youth in clear, direct ways. Emphasize parental monitoring of the youth's activities e. Encourage enforcement of curfews. Encourage parents and youth to discuss rewards for appropriate behavior and consequences for misbehavior such as staying out after curfew. Rewards and consequences should be discussed ahead of time, ideally in a session with a health care professional who can facilitate communication.
Encourage parents to coordinate with school personnel, including school social workers, around any concerns in the school setting. All professionals involved in treating the youth should coordinate care to ensure that all are aware of comorbidities, concerns, and approaches to treatment. Encourage structuring of the youth's time and activities, including after school time, to minimize times when he or she is not monitored by a responsible adult such as a teacher, coach, or parent.
Ensure that comorbidities such as ADHD, substance use, and mood or anxiety disorders are treated. If the youth has his or her own phone and social media account, encourage the parents and youth to review texts and social media posts together, with discussion about how the messages affect all parties involved. Provide the parents and youth with options for healthy activities, such as sports teams, school clubs, church activities, community groups such as Scouts, and mentoring organizations such as Big Brothers Big Sisters of America.
Recommend that parents and youth establish a daily routine of engaging in play or an enjoyable activity together e. The physician should emphasize the benefits of overall stress reduction in the home, 17 warmth in parental interactions with the child, and avoidance of harsh discipline. Participation in high school sports can reduce the association between conduct disorder and adult antisocial behavior and could be considered an intervention to reduce the symptoms of conduct disorder.
Parents should also be encouraged to treat their own mental health concerns. The most recent U. Most of these psychosocial treatment methods were developed at universities and are marketed toward systems such as school districts or health care systems, which often finance training through grants. The treatments take years to implement and therefore may not be accessible to most physicians. There are websites that provide links for finding local health care professionals who use these methods eTable A.
The physician may need to network with local psychologists and ask them if they treat conduct disorder, or collaborate with schools and determine whether they have a formal approach for treating conduct disorder. Developed at University of Miami; many websites have information, including www. Family intervention designed for children six to 18 years of age with substance use or behavioral issues; typically 12 to 16 family sessions in the office.
Designed for fourth to sixth graders with disruptive behaviors; child and parent components; sessions at school. Girls are more prone to deceitful and rule-violating behavior. If your child has mild symptoms, it means they display little to no behavior problems in excess of those required to make the diagnosis. Conduct problems cause relatively minor harm to others. Common issues include lying, truancy, and staying out after dark without parental permission.
Your child has moderate symptoms if they display numerous behavior problems. These conduct problems may have a mild to severe impact on others.
The problems may include vandalism and stealing. Your child ha severe symptoms if they display behavior problems in excess of those required to make the diagnosis. These conduct problems cause considerable harm to others.
The problems may include rape, use of a weapon, or breaking and entering. Genetic and environmental factors may contribute to the development of conduct disorder. Damage to the frontal lobe of the brain has been linked to conduct disorder. The frontal lobe is the part of your brain that regulates important cognitive skills, such as problem-solving, memory, and emotional expression.
The frontal lobe in a person with conduct disorder may not work properly, which can cause, among other things:. The impairment of the frontal lobe may be genetic, or inherited, or it may be caused by brain damage due to an injury. A child may also inherit personality traits that are commonly seen in conduct disorder.
If your child is showing signs of conduct disorder, they should be evaluated by a mental health professional. For a conduct disorder diagnosis to be made, your child must have a pattern of displaying at least three behaviors that are common to conduct disorder.
Your child must also have shown at least one of the behaviors within the past six months. The behavioral problems must also significantly impair your child socially or at school. Children with conduct disorder who are living in abusive homes may be placed into other homes.
If your child has another mental health disorder, such as depression or ADHD, the mental healthcare provider may prescribe medications to treat that condition as well. Since it takes time to establish new attitudes and behavior patterns, children with conduct disorder usually require long-term treatment.
However, early treatment may slow the progression of the disorder or reduce the severity of negative behaviors. Children who continuously display extremely aggressive, deceitful, or destructive behavior tend to have a poorer outlook. Despite early reports that treatment for this disorder is ineffective, several recent reviews of the literature have identified promising approaches treating children and adolescents with conduct disorder.
The most successful approaches intervene as early as possible, are structured and intensive, and address the multiple contexts in which children exhibit problem behavior, including the family, school, and community.
Examples of effective treatment approaches include functional family therapy, multi-systemic therapy, and cognitive behavioral approaches which focus on building skills such as anger management. Pharmacological intervention alone is not sufficient for the treatment of conduct disorder. Conduct disorder tends to co-occur with a number of other emotional and behavioral disorders of childhood, particularly Attention Deficit Hyperactivity Disorder ADHD and Mood Disorders such as depression.
Co-occurring conduct disorder and substance abuse problems must be treated in an integrated, holistic fashion.
Accurate assessment and appropriate, individualized treatment will assure that all children are equipped to navigate the developmental milestones of childhood and adolescence and make a successful adaptation to adulthood. Treatment must be provided in the least restrictive setting possible. Going to a party or even having a one-on-one conversation with a new person can result in increased heart rate, sweating, and racing thoughts for someone with social anxiety. Conduct Disorder.
Signs and Symptoms.
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