Clinical Practice Guidelines for the management of conduct disorder.

Abstract

Conduct disorder (CD) and associated antisocial behavior is one of the most common mental and behavioral problems in children and young people. In the United States, CDs associated behaviors are primary presenting complains in children and adolescent. CD are characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct (ICD-10). Associated behaviors are outside the socially accepted norms that results into persistent and significant violations of age appropriate social expectations. CD is classified along with the diagnosis of oppositional defiant disorder (ODD) in the spectrum of disruptive behavior disorders. ODD can be seen as precursor to the development of CD. Behaviors include stealing and lying, excessive physical and verbal aggression, rule breaking and violence. Persistence of these behaviors into adulthood leads to antisocial personality disorder (ASPD). As these behaviors are present in some children during the course of development, it is essential for the clinician to differentiate between normalcy and pathological behavior. Remote antisocial or illicit acts are not enough to support a diagnosis of CD. CD must be differentiated from other term like delinquency. CD is a mental and behavioral disorder while delinquency is a legal term. It is comorbid with many other psychiatric conditions, including attention deficit hyperactive disorder (ADHD), depression, substance use disorders, etc. CD in early life has been found to be strongly associated with significant decline in educational performance. They are more likely to remain socially isolated with increase in substance misuse during adolescence. There is increase involvement in criminal acts resulting in frequent contact with the criminal justice system. This adverse effect continues even in adult life with resulting poorer educational and occupational outcomes. There are limited data available about the prevalence of CD across the world. Using the diagnostic and statistical manual of mental disorders-III (DSM-III) and DSM-III-R diagnostic guidelines, the prevalence of CD in the United States was found to be 6%–16% in males and from 2% to 9% in females. With a clinical interview as a method of detection, the prevalence of CD in the general population is found to be between 1.5% and 4%. Boys are likely to have these conditions two times more than girls. Those with early-onset exhibit lower IQ compared to children with later age of onset. They have more attention deficits and impulsivity problems. It is comorbid with many other psychiatric conditions including ADHD, depression, substance use disorders, etc., Children with CD also find difficulty in interacting and integrating with peer group and are more likely to had adverse family circumstances. Increased risk factors include poor prenatal care and poor infant nutrition, poverty, physical abuse, and more crime in the neighborhood society. Families of children and adolescent with CD are more likely to exhibit parents with low income, substance abuse, depression, somatization, and ASPD. CD in early life has been found to be strongly associated with significant decline in educational performance. They are more likely to remain socially isolated with increase in substance misuse during adolescence. There is increase involvement into criminal acts resulting into frequent contact with the criminal justice system. This adverse effect continues even in adult life with resulting poorer educational and occupational outcomes. Large numbers of etiological factors for CD have been highlighted in various studies. With the increase in risk factors possibility of developing CD increases. Genetic liability along with various environmental factors acts together for the manifestation of behavioral symptoms of CD. Magnetic resonance imaging has been used to compare structural brain differences between children with CD and normal controls and have documented smaller brain structures and lower brain activity in children with CD. Abnormalities are primarily detected in the bilateral amygdala, right striatum, bilateral insula and left medial/superior frontal gyrus as well as the left precuneus in individuals having ODD/CD. Higher plasma levels of serotonin in blood are positively associated with aggressive behavior in children. Impulsiveness and aggression along with violent behavior have been found to be associated with alteration in the activity of certain brain structures. Areas mainly associated and affected are limbic structures and the anterior cingulate and orbitofrontal areas of the prefrontal cortex. Parental psychopathology along with harsh parenting is associated with CD in their children. The presence of antisocial behavior in children has been found to be associated with parental reinforcement, their responsiveness to the child and punishment given by them. Frequent marital conflicts between parents and interparental violence predict adolescent antisocial behavior. Children with CD have been found disproportionately coming from low-income family and with unemployed parents. Inadequate housing, poverty, and crowding exerts negative influence on the development of the child. Exposure to and prevalence of substance use in the community have also been found significantly associated with the development of CD. Availability of drugs and increased crime in the neighborhood increases the risk of children developing CD. Peer relation also significantly affects the development and maintenance of these behaviors.