Conduct Disorder
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The diagnosis of Conduct Disorder is used for a repetitive and persistent pattern of violating the basic rights of others or major age-appropriate societal norms or rules.  These are broken into four main groups: 1) Aggressive conduct of causing or threatening physical harm to people or animals. 2) Destruction of the property of others, 3) deceitful or lying behavior and stealing, and 4) serious rule violations.  Three or more of these must be present during the past 12 months.  The diagnosis can be used for individuals over age 18 if they do not qualify for Antisocial Personality Disorder.

Informants are important in making the diagnosis since many of the individuals with Conduct Disorder will not reveal the information.  Aggression may be bullying. threatening, or intimidating others.  Initiating frequent physical fights, using weapons, physical cruelty, and forced sexual activity fall under aggression.  Deliberate property destruction includes fire setting with a destructive intent, smashing car windows, school vandalism, etc.  Deceit includes frequent lying or breaking of promises to obtain goods and favors or to avoid debts or obligations.   Serious rule violations include at school and in the home.  This would include staying out late without permission, running away, truancy from school, missing work without a good reason, etc.

The Childhood-Onset Type with onset before age 10 is more severe and more likely to go on to Antisocial Personality Disorder.  The Adolescent-Onset Type are less likely to show aggressive behaviors and are more conduct problems in the company of others.  The male predominance is stronger with the Childhood Onset.

Conduct Disorder individuals may have less empathy for others and little concern for their feelings.  They may lack feelings of guilt or remorse.  They may blame others for their own misdeeds.  Low frustration tolerance, irritability, temper problems, and recklessness are common.  Early sexual behavior, drinking, smoking, and illicit substance abuse are common.  Conduct Disorder is associated with lower intelligence. ADHD is common.  Parental harsh discipline, inconsistent child-rearing practices, physical abuse, lack of supervision, and association with a delinquent peer group are common.

The prevalence of Conduct Disorder is 6% to 16% of males under age 18 and 2% to 9% of females.  It may start as early as age 5 but usually begins in late childhood or early adolescence.  There is some genetic tendency for it to run in families.  It is also more common in children of parents with alcohol, mood, or ADHD problems.

Medication can be of value in some cases although counseling and environmental changes may be even more important.  Some research has found that a vitamin-mineral-fatty acid supplement can have a significant impact.  Indeed, the research is solid enough to suggest that all children with the disorder should be on good daily supplements.  Since the field of child psychiatry has mushroomed over the past 15 years, many of the older medications, which are no longer covered by patents, have little research funded to examine their usefulness.  None of the studies compare two medications to each other.  One study found that half of the youth had their chronic aggression clear without medications within the first two weeks of hospitalization.  A small amount of evidence from two studies of desipramine and bupropion suggest that anti-depressants may help some youth, but there are no studies specifically using anti-depressants.

Although risperidone is the only atypical anti-psychotic studied in double-blind research to date, there is no reason to think that it would be superior to other atypical anti-psychotics. 

Medication Research

Research Reviewed: 17 controlled studies and six open trials. Investigated compounds mainly belong to three classes of psychotropic drugs: mood stabilizers, neuroleptics and stimulants (six, five and six controlled studies, respectively). Lithium is the most documented treatment (3/4 positive studies). Conventional neuroleptics have been most commonly prescribed (3/3 positive studies), atypical neuroleptics appear promising (2/2 positive studies). Methylphenidate improves some CD symptoms, even in the absence of ADHD (6/6 positive studies). Paris. Drug treatment of conduct disorder in young people. Gerardin P, Cohen D, Mazet P, Flament MF. Eur Neuropsychopharmacol. 2002 Oct;12(5):361-70

Half Respond When Hospitalized Without Any Medication: In a two week baseline evaluation before starting a PC DB study, 21 of 44 (48%) youth 10-17 years old admitted for chronic and severe aggression responded without any medication. The authors suggest not giving medication to youth immediately on admission. Med College of Pennsylvania. Nonpharmacological response in hospitalized children with conduct disorder. Malone RP, Luebbert JF, Delaney MA, Biesecker KA, Blaney BL, Rowan AB, Campbell M. J Am Acad Child Adolesc Psychiatry. 1997 Feb;36(2):242-7

Carbamazepine Didn't Help in Small DB: In a PC DB study of 22 children 5-12 years old treated for 6 weeks with carbamazepine 400-800 mg/d or placebo, no significant benefit was found. Side-effects were significant. Carbamazepine in aggressive children with conduct disorder: a double-blind and placebo-controlled study. Cueva JE, Overall JE, Small AM, Armenteros JL, Perry R, Campbell M. J Am Acad Child Adolesc Psychiatry. 1996 Apr;35(4):480-90. (Ed: Such small studies don't mean much, especially when they don't find significant difference.)

Divalproex Helped Explosive Temper and Mood Lability in Small DB: 20 children and adolescent out-patients with a disruptive behavior disorder (oppositional defiant disorder or conduct disorder) met the specific criteria for explosive temper and mood lability and were treated in a crossover study.  In the first phase, 8 of 10 responded to divalproex and 0 of 10 to placebo.  Only 15 finished both phases with 80% responding to divalproex. Divalproex treatment for youth with explosive temper and mood lability: a double-blind, placebo-controlled crossover design. Donovan SJ, Stewart JW, Nunes EV, Quitkin FM, Parides M, Daniel W, Susser E, Klein DF. Am J Psychiatry. 2000 May;157(5):818-20

Divalproex High Dose Helped Serious Conduct Disorder Teens: A 6 week, randomized, single-blind study of 66 Conduct Disorder teens were randomized to divalproex 250mg/d or less vs. 500-1500 mg/d (50-120 microg/L). Both groups started at 125 mg/d. The groups averaged 125 mg/d at the end vs. 1000 mg/d. CGI-S (Severity of Illness) and CGI-I (Improvement) both did significantly better with the high dose (p=.02 and .0008). Weekly impulse control was better with the higher dose. While all patients had conduct disorder, 88% also had substance abuse, 60% were diagnosed with learning disability, 54% dysthymia/depression, and 52% ADHD. Their average age was 15.9 (14-18). They received no other medication. All had committed at least one offense against persons and 66% had committed a serious violent crime (manslaughter, robbery or rape). Steiner H, et al. Divalproex sodium for the treatment of conduct disorder: a randomized controlled clinical trial. J Clin Psychiatry 10/2003;64:1183-91. Stanford. Funded by Abbott Labs, maker of divalproex.

Fish Oil May Have Lowered Aggression in Grade School Girls: In a DB PC study of 166 children ages 9-12, fish oil group took fish oil-fortified foods (bread, sausage and spaghetti) equivalent to 2 capsules of fish oil per day for 3 months. Physical aggression in girls increased significantly (median: 13 to 15) in the control group and did not change (13 to 13) in the fish oil group (P=.008). No significant changes in physical aggression occurred in boys. Impulsivity of girls assessed by parents/guardians using the diagnostic criteria for attention deficit/hyperactivity disorder of DSM-IV was reduced in the fish oil group (1 to 0) with a significant (P=.008) intergroup difference from the control group (1 to 1). The effect of fish oil on physical aggression in schoolchildren - a randomized, double-blind, placebo-controlled trial. Itomura M, Hamazaki K, et al. Toyama Medical University, Japan. J Nutr Biochem. 2005 Mar;16(3):163-71.

Fish Oil Lowered Truacy, Improved Learning: Slices of bread smeared with a fish oil enriched spread can improve kids' spelling and stop them missing school. South African researchers have told an Australian scientific conference that primary school children who were given daily doses of fish oil as part of a study showed improved learning and memory. Marius Smuts, from the Nutritional Intervention Research Centre in South Africa, tracked the development of 355 children aged between six and nine. Half were given two slices of bread covered with 25 grams of spread enriched with fish oil but flavored with either chicken, curry or tomato sauce. The children were able to retain information better and were less inclined to take sick days. Another study also reported to the conference found Omega 3 supplements taken by primary school students in Thailand reduced the severity and duration of common illnesses. Researchers recommend at least 400mg of Omega 3 in their food each day, but most Americans don't even get half of this. 7/31/06 Congress of the International Society for the Study of Fatty Acids and Lipids in Cairns, Australia. BBC News. 

Haloperidol and Lithium Each Helped Conduct Disorder Aggression in DB: A PC DB study of 61 children with severe aggression problems were treated with haloperidol (1-6 mg/d), lithium (500-2000 mg/d), or placebo.  Both active medication groups improved although side-effects were worse with haloperidol. Behavioral efficacy of haloperidol and lithium carbonate. A comparison in hospitalized aggressive children with conduct disorder. Campbell M, Small AM, Green WH, Jennings SJ, Perry R, Bennett WG, Anderson L. Arch Gen Psychiatry. 1984 Jul;41(7):650-6

Lithium Helped Conduct Disorder with Severe and Persistent Aggression: A 4 week PC DB study of 40 adolescents with severe and persistent aggression were study.  The lithium group had an 80% response rate vs. 30% of those on placebo.  Lithium side-effects of nausea, vomiting, and urinary frequency were a problem. A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. Malone RP, Delaney MA, Luebbert JF, Cater J, Campbell M. Arch Gen Psychiatry. 2000 Jul;57(7):649-54. Hahnemann Univ.

Lithium Helped Severe Aggression in DB: In a 6 week PC DB study of children with severe aggression, lithium at 1.12 mEq/L average did better than placebo. New York Univ. Lithium in hospitalized aggressive children with conduct disorder: a double-blind and placebo-controlled study. Campbell M, Adams PB, Small AM, Kafantaris V, Silva RR, Shell J, Perry R, Overall JE. J Am Acad Child Adolesc Psychiatry. 1995 Apr;34(4):445-53

Methylphenidate Helped Conduct Disorder Anti-Social Behavior: A study of 84 children with CD, 6-15 years old, gave methylphenidate (up to 60 mg/d) or placebo for 5 weeks. Behavior was evaluated by parent, teacher, and clinician reports and by direct classroom observations. Two thirds also met criteria for ADHD. Ratings of antisocial behaviors specific to CD were significantly reduced by methylphenidate treatment. The magnitude of methylphenidate effect indicated meaningful clinical benefit. Partialling out severity of ADHD did not alter the significant superiority of methylphenidate on CD ratings specifically (P < .001). Clinical efficacy of methylphenidate in conduct disorder with and without attention deficit hyperactivity disorder. Klein RG, Abikoff H, Klass E, Ganeles D, Seese LM, Pollack S. Arch Gen Psychiatry. 1997 Dec;54(12):1073-80

Risperidone Better than Placebo for Aggressive Behavior: In a 6-week DB PC study of 163 boys, ages 5-12, with or without comorbid attention-deficit/hyperactivity disorder and with a either conduct disorder or oppositional defiant disorder, risperidone solution (0.01-0.06 mg/kg/day) resulted in a greater decrease in aggressive behavior (56% vs. 22%, p<.001). Subjects had below average intelligence [intelligence quotient (IQ) 36-84] and a score of > or =24 on the Conduct Problem subscale of the Nisonger Child Behaviour Rating Form (N-CBRF). An expert advisory panel selected six core aggression items from the N-CBRF, from which a total Aggression Score (AS, range 0-18) was constructed. Risperidone reduces aggression in boys with a disruptive behaviour disorder and below average intelligence quotient: analysis of two placebo-controlled randomized trials. LeBlanc JC, et al. Dalhousie University, Halifax, Canada. . Int Clin Psychopharmacol. 2005 Sep;20(5):275-83.

Risperidone Better Than Placebo for Disruptive Conduct Problems: A PC DB study of 110 children 5-12 years old with high scores on conduct problems (aggression, impulsivity, defiance of authority figures, and property destruction) on the Conduct Problem subscale of the Nisonger Child Behavior Rating Form were studied.  80% were also diagnosed ADHD.  IQs ranged from 36 to 84.  Risperidone doses ranged from 0.02 to 0.06 mg/kg per day.  Conduct problems decreased 47% vs. 21% for placebo.  The effect of risperidone was unaffected by diagnosis, presence/absence of ADHD, psychostimulant use, IQ status, and somnolence. Risperidone produced no changes on the cognitive variables (CPT/modified CVLT). The most common side effects included somnolence, headache, appetite increase, and dyspepsia. Side effects related to extrapyramidal symptoms were reported in 13% on risperidone and 5% on placebo. Effects of risperidone on conduct and disruptive behavior disorders in children with subaverage IQs. Snyder R, Turgay A, Aman M, Binder C, Fisman S, Carroll A; Risperidone Conduct Study Group. J Am Acad Child Adolesc Psychiatry. 2002 Sep;41(9):1026-36.  The same authors report in a longer open trial that somnolence (52%), headache (38%), and weight gain (36%) were the most common adverse events, but that the severity of side-effects were minor. Pediatrics. 2002 Sep;110(3):e34. Univ. Toronto

Risperidone Did Better Than Placebo for Aggression in Small DB for Conduct Disorder: 20 Conduct Disorder youth treated in a PC DB study over 10 weeks with risperidone increased to 1.5 mg/d or even 3.0 mg/d for those weighing over 110 pounds. Case-Western Univ. A double-blind pilot study of risperidone in the treatment of conduct disorder. Findling RL, McNamara NK, Branicky LA, Schluchter MD, Lemon E, Blumer JL. J Am Acad Child Adolesc Psychiatry. 2000 Apr;39(4):509-16