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Patients and relatives What should I (or my kid) know about disruptive disorders?

What should I (or my kid) know about disruptive disorders?

Description of conduct disorder
What are the differences between occasional conduct problems and conduct disorder?
What are the differences between conduct disorder and delinquency?
How frequent is conduct disorder?
What do we know about risk factors/causes of conduct disorder?
What is the outcome of conduct disorder?
What non-pharmacological treatments have shown efficacy in conduct disorder?
What are the pharmacological options in conduct disorder?

Description of conduct disorder

Conduct disorder is a behavior disorder that occurs in children and adolescents. Youngsters with conduct disorder show persistent behaviors that violate the basic rights of other people or major age-appropriate societal rules.

Conduct disorder is characterized by several anti-social and aggressive behaviors that last over a given period of time (6 month to 12 month depending on the diagnostic criteria one refers to). Main features of conduct disorder are: aggression to people and animals, destruction of property, deceitfulness or theft, serious violations of rules. Some children and adolescents show a predominance of overt antisocial behavior such as reactive aggression, theft with confrontation, use of weapons, while some show more covert antisocial behaviors like truancy, lying or stealing without confrontation. Severity of conduct disorder as well as age of onset is variable. In mild severity conduct disorder, symptoms are just at the level needed to make a diagnosis (three anti-social behaviors in the previous 12 months or one in the previous 6 months) and social consequences are significant but impairment is limited. In severe conduct disorder, antisocial symptoms are numerous, and considerably harmful for the affected child or adolescent and for people of his social environment. When conduct disorder starts before the age or ten, it is called childhood-onset as opposed to adolescent-onset conduct disorder.

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What are the differences between occasional conduct problems and conduct disorder?

Mild and occasional conduct problems can be seen in normally developing children/adolescents. In the general population, aggressive behavior tends to decrease across the first 10 years of life. In youngsters with conduct disorders, aggressive behavior or other conduct problems are frequent, chronic and have negative consequences on their social, academic and family life. A significant proportion of children/adolescents with transient or moderate antisocial behaviors do not meet criteria for conduct disorder.

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What are the differences between conduct disorder and delinquency?

Although conduct disorder heightens risk for delinquency, the first is a category of mental health problems and the latter is a legal term referring to offenses against the law. Conduct disorder is a serious public health concern because it is often associated with other mental health problems (depression/suicidal acts, substance abuse/dependency) risk-taking behaviors, legal complications and family conflict.

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How frequent is conduct disorder?

Conduct disorder is a prevalent category of mental health problems. The prevalence of conduct disorder in the general population is estimated to be 1,5-3,4% (Steiner 1997). An increase in prevalence has been documented in the last years, but it remains unclear if this is related to improved recognition or varying definitions of conduct disorder. The diagnosis of conduct disorder is more frequent in boys, but the “covert” symptoms in girls (compared with more overt aggressive behaviors in males with conduct disorder) have been incriminated in possible under-diagnosis in this population. Peak age at onset is late childhood.

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What do we know about risk factors/causes of conduct disorder?

Conduct disorder is currently considered a multidetermined condition involving both biological and environmental factors, and most certainly resulting from different developmental trajectories. Although diverse, trajectories leading to conduct disorder are likely to share accumulation of risk factors and lack of protective factors.

Behavioral genetic studies show moderate influence of genetic factors in the etiology of conduct disorder; influence of genetic factors appear to be highest in early-onset, pervasive conduct disorder and in children/adolescents with conduct disorder and callous-unemotional traits. Molecular genetic studies have shown associations between genes of several neurotransmitter systems and conduct disorder. Some genetic factors moderate the impact of environmental adversity; for example, gene-environment interactions influence developmental risk for conduct problems, aggression and violence in children exposed to maltreatment (Caspi et al. 2002).

Dysfunctional family relations as well as parental abuse/neglect, poor parenting and family adversity have been associated with development and reinforcement of conduct problems. Parental psychopathology (especially a family history of conduct disorder/antisocial personality and substance use) is also related to elevated risk for conduct problems in children. During adolescence, influence of peers becomes increasingly important; some conduct problems may arise or be maintained by affiliation with deviant peers. On the contrary, familial and peer relationships can also be protective and attenuate the effect of other risk factors.

The impact of environmental factors may be modified by individual characteristics like temperament, social skills, and IQ. Difficult temperament, poor social skills as well as low verbal IQ and school failure have been associated with conduct disorder.

Both attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder are risk factors for conduct disorder and frequent comorbidities. When conduct disorder is associated with ADHD, it is generally particularly impairing and associated with poor functional outcome. Chronic illness and perinatal factors have also been associated with a heightened risk for conduct disorder in subsequent development.
Several other conditions are frequent in youngsters with conduct disorder. These include substance use/abuse, depressive disorders, anxiety disorders, suicidal ideation/acts) and learning disorders.

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What is the outcome of conduct disorder?

Follow-up studies showed moderate to strong stability of conduct problems across ten years. Conduct disorder severity (i.e. number of symptoms) seems to be a major predictor of later functional outcome in various domains (relational, professional, legal, mental and physical health). Co-occurring ADHD (especially the hyperactive/impulsive dimension) is associated with severity, persistence and early age of onset of CD.

Conduct disorder is often preceded by Oppositional Defiant Disorder (ODD), which is characterized by defiant, oppositional and negative behaviors that last longer and are more severe than expected during normal development.

A significant proportion of children with ODD (about 40% to 60%) will develop conduct disorder, but this progression is far from systematic. Most children/adolescents with conduct disorder also have symptoms of ODD. Progression from conduct disorder to antisocial personality disorder, a chronic condition of adulthood, characterized by extreme disregard for others and societal norms, follows a similar pattern: one third to a half of youngsters with conduct disorder will meet criteria of this personality disorder in adulthood.

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What non-pharmacological treatments have shown efficacy in conduct disorder?

Multisystemic treatment approaches have the best evidence base in the treatment of conduct disorder. These involve a multidisciplinary team (generally including psychiatrists, neuro-psychologists, social workers, family therapists, nurses, educators…) and an individually tailored treatment plan. Programs derived from Parent Management Training in group or individual settings, have shown efficacy in controlled trials to reduce oppositional behaviors. Their therapeutic impact is greater in pre-pubertal children versus adolescents and when conduct problems are mild or moderate. Social skills training and cognitive skills training, as well as family therapy can be part of a multisystemic treatment plan.

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What are the pharmacological options in conduct disorder?

Currently, there is no labeled mediation for conduct disorder or aggression related to conduct disorder in normal IQ children and adolescents.

Psychostimulants have shown efficacy in reducing disruptive behaviors in children having both symptoms of conduct disorder and attention deficit/hyperactivity disorder (ADHD) but seem to have less impact on conduct symptoms without ADHD. Mood stabilizers and alpha-2-agonists have shown moderate effects on aggressive symptoms. Low doses of typical antipsychotics also reduce aggressive symptoms but their use is limited because of their neurological side effects. Risperidone is the most extensively studied newer generation antipsychotic but the majority of trials have included participants with sub-average IQ. More information is needed on efficacy in normal IQ children and adolescents with CD, maintenance of therapeutic effects, long term tolerance and safety. Although newer generation antipsychotics show less neurological side effects in comparison with older antipsychotics, endocrine/metabolic side effects (weight gain, elevated glucose levels) are frequent and potentially impairing side effects of these medications requiring specific vigilance in the pediatric population.

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