The American Psychiatric Association (APA) lists the category of Disruptive, Impulse Control, and Conduct Disorders as disorders that involve issues with a person’s control of their emotions and behaviors. These disorders specifically involve problems that occur with behaviors that violate the rights of others or that result in the individual having significant conflicts with authority figures or societal norms. The types of causes and manifestations of issues that occur within this category of disorders can be numerous and can vary quite a bit from a disorder to disorder within the category. Conduct disorder is one of these disorders that are categorized within this classification.
What Is Conduct Disorder?
Conduct disorder is diagnosed when the individual displays a persistent and repetitive pattern of violating the basic rights of other people or violating age-appropriate rules or regulations. Conduct disorder is typically not diagnosed in individuals who are over the age of 18, although under very special conditions, it can be. Instead, most individuals who display behaviors associated with conduct disorder and are over the age of 18 would be more likely to be given a diagnosis of antisocial personality disorder.
Only a trained mental health clinician can diagnose conduct disorder. The diagnosis of conduct disorder is made on the basis of behavioral symptoms that are formally listed in the APA’s Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5). The diagnostic criteria consist of 15 major criteria from four categories. In order to receive a formal diagnosis of conduct disorder, the person must meet at least three of these diagnostic criteria over a 12-month period with at least one of them being present in the last six months. The categories of criteria used to diagnose conduct disorder include:
- Displaying aggression to animals or to people
- Destruction of property
- Theft and/or significant deceitfulness (e.g., significant, repetitive lying)
- Serious rule violations
Individuals with conduct disorder can be diagnosed as a child-onset type (diagnostic criteria being met before the age of 10) or as an adolescent-onset type (showing symptoms after the age of 10). The onset of the disorder may also be unspecified, such that it cannot be determined when the symptoms first appeared.
Individuals with conduct disorder may also be diagnosed with specifiers that indicate that they have some pro-social features to their presentation, lack remorse or feelings of guilt, lack empathy for other people, show a lack of concern about their behavior, or have very little emotional expression. Conduct disorder can be diagnosed as mild in its presentation (few symptoms), moderate, or severe.
The prognosis for treating conduct disorder depends on its severity, age of onset, and other associated features, such as lack of empathy or remorse. The individual’s social situation, such as the strength of family bonds, their peer group, ability to relate to authority figures, etc., also play important roles in the person’s prognosis. A large number of individuals diagnosed with conduct disorder are later diagnosed with antisocial personality disorder, a very severe personality disorder that often results in individuals having significant legal entanglements and being incarcerated.
Other Features of Conduct Disorder
The context of the behaviors that occur with conduct disorder should be considered before formal diagnosis is made. Children may exhibit patterns of disruptive behavior that are viewed by other cultures as dysfunctional when they are, in fact, consistent with the values of the culture.
Males who are diagnosed with conduct disorder tend to exhibit issues with physical aggression, vandalism, theft, and discipline in school, whereas females are more likely to have issues with deceitfulness, truancy from school, running away, substance abuse, and even prostitution. There are numerous considerations when a diagnosis of conduct disorder is being considered, including being able to distinguish conduct disorder from other potential psychological disorders that have similar presentations, such as oppositional defiant disorder, adjustment disorders, intermittent explosive disorder, attention deficit hyperactivity disorder (ADHD), and even disorders of mood, such as depression and bipolar disorder.
According to APA, children diagnosed with conduct disorder often have comorbid disorders, such as ADHD and oppositional defiant disorder. Other disorders may also be comorbid (co-occur) with conduct disorder, including learning disorders, anxiety disorders, and substance abuse.
Conduct Disorder and Alcohol Abuse
Research studies have found significant comorbidities with substance abuse and other mental health disorders. Conduct disorder is often comorbid with several different substance use disorders, particularly alcohol use disorders. For instance, an earlier study, published in 1997 using data from a large epidemiological study, found that in the sample of research participants, nearly 42% of the men diagnosed with conduct disorder met the diagnostic criteria for alcohol dependence. In addition, nearly 23% percent of the women diagnosed with conduct disorder met the diagnostic criteria for alcohol dependence.
Numerous other studies have found similar high comorbidities between alcohol abuse and conduct disorder, particularly for the adolescent onset subtype of conduct disorder. Research has also found an increased risk for a young person diagnosed with conduct disorder to develop an alcohol use disorder if one or both parents also had alcohol abuse issues.
Various explanations have been put forth to explain the high rates of comorbidity between conduct disorder, substance use disorders, and other mental health disorders. For instance, a recent neuroimaging study using functional magnetic resonance imaging found that individuals with comorbid externalizing disorders (e.g., ADHD, conduct disorder) and substance abuse issues displayed deficits in the activation of areas of the brain that are involved in controlling impulsive behaviors, in understanding potential errors of judgment, and in the ability to selectively experience reinforcement. Researchers suggested that these deficits are most likely due to a combination of inherent factors and environmental experiences; however, these types of studies have little diagnostic utility and are purely speculative.
When an individual is diagnosed with a mental health disorder, such as conduct disorder, and a comorbid substance use disorder, such as an alcohol use disorder, this condition is usually referred to as a dual diagnosis or co-occurring disorders.
Treatment for Co-Occurring Conduct Disorder & Alcohol Abuse
APA reports that when an individual is diagnosed with a conduct disorder at an early age, they are likely to continue to have ongoing problems throughout their life if their families do not get them involved in some type of early intervention. There is a positive relationship between a diagnosis of conduct disorder as an adolescent or child, or even just having repetitive conduct problems as an adolescent or child, and later diagnosis of antisocial personality disorder. These individuals often have difficulty adapting to the demands of adulthood, such as maintaining fairly stable relationships and employment. They are at a high risk to become incarcerated or have other legal issues. Individuals with conduct disorder and comorbid alcohol use disorder are even more likely to have significant issues in adulthood if these conditions are not addressed early.
According to the book Conduct Disorder, treatment for conduct disorder should start with a comprehensive evaluation performed by a licensed mental health professional. The evaluation should draw from numerous sources, including the child (adolescent), family members, teachers, other medical professionals who treat the child, and even get information from the legal system if there is legal involvement. This evaluation should be designed to address numerous areas of functioning and to identify any co-occurring conditions that will need treatment.
Formal treatment of an individual with conduct disorder can be very challenging and complex. Children or adolescents diagnosed with conduct disorder often have a general distrust of adults and are uncooperative with rules and regulations. There are no medications that can directly address the symptoms associated with conduct disorders; however, medications can be used for symptoms of co-occurring conditions, including medications that can be useful in treating withdrawal in individuals with alcohol use disorders, increasing attention and focus in individuals with comorbid ADHD, decreasing levels of anxiety, and dealing with other issues of mood, such as depression.
Forms of behavioral therapy and family therapy are the preferred treatments for conduct disorders. Other useful treatments that can be incorporated into the care plan include:
- Various forms of Cognitive Behavioral Therapy
- Contingency Management (a behavioral therapy that offers reinforcement for prosocial behavior and abstinence from substances)
- Motivational Interviewing (a cognitive-behavioral approach that determines the individual’s understanding of their need to change and then works from that point to help them change)
- Experiential therapies that the person finds satisfying, such as music therapy, wilderness therapy, art therapy
Parents often need expert assistance to incorporate the issues worked on in therapy into everyday life. Numerous home-based treatment programs and family therapy can help achieve these goals. Treatment for conduct disorder is typically long-term because these issues do not readily remit even after years of intervention. Often, treatment is ongoing.
Individuals with co-occurring disorders that consist of a conduct disorder and an alcohol use disorder present even more challenges in treatment. At one time, it was believed that simply treating conduct disorder would result in a remission of the substance use disorder, such as an alcohol use disorder; however, experience and research studies have found that this is not a sound approach. Instead, individuals with dual diagnoses and/or other comorbid conditions need to have all conditions addressed simultaneously. Thus, part of the treatment for an individual with a co-occurring conduct disorder and alcohol use disorder would be devoted to incorporating substance use disorder treatment into the program to address conduct disorder. Typically, individuals with dual diagnoses are treated by a multidisciplinary team of treatment providers who address specific issues and work together to produce an overall effect.
Multidisciplinary teams that treat individuals with co-occurring conditions often consist of psychiatrists, addiction medicine physicians, other physicians, therapists, counselors, social workers, case managers, speech therapists, tutors, occupational therapists, etc. Each of these treatment providers works within their specialty, and the members of the team meet at scheduled intervals to discuss the progress of the client, to continue to develop a treatment plan, and to implement changes.
The treatment of the alcohol use disorder in individuals with comorbid conduct disorder and alcohol use disorder would consist of medications when necessary, specialized substance use disorder therapy, participation in social support groups that are composed of individuals similar in age, and other ongoing interventions that could include complementary and alternative treatments, such as art therapy, music therapy, wilderness therapy, etc. Individuals with co-occurring conduct disorder and alcohol abuse issues often need years of monitoring and participation in treatment-related activities to maintain recovery.