CONDUCT DISORDER - QUESTION 1 (20 Marks): Clinical Overview

CONDUCT DISORDER

1. DEFINITION

2. EPIDEMIOLOGY

• Prevalence in the United States: 6-16% in males, 2-9% in females
• Male-to-female ratio ranges from 4:1 to 12:1
• Occurs with higher frequency in children of parents with antisocial personality disorder and alcohol use disorder
• Prevalence is associated with socioeconomic factors and parental psychopathology
• Average age of onset is younger in boys (10-12 years) than in girls (14-16 years)

3. DSM-5-TR DIAGNOSTIC CRITERIA

1. Often bullies, threatens, or intimidates others
2. Often initiates physical fights
3. Has used a weapon capable of causing serious physical harm (bat, knife, gun)
4. Has been physically cruel to people
5. Has been physically cruel to animals
6. Has stolen while confronting a victim (mugging, armed robbery, extortion)
7. Has forced someone into sexual activity

4. SUBTYPES AND SPECIFIERS

Age-of-Onset Subtypes:

Specifier - "With Limited Prosocial Emotions" (LPE):

• Lack of remorse or guilt - does not feel bad when doing something wrong
• Callous lack of empathy - cold, uncaring, disregards feelings of others
• Unconcerned about performance - does not show concern about poor performance at school/work
• Shallow or deficient affect - does not express genuine emotions, or uses emotions to manipulate

Children with the LPE specifier are more likely to have childhood-onset type, meet criteria for severe disorder, and have worse prognosis.

Severity:

• Mild: Few conduct problems above the minimum, minor harm to others (lying, truancy)
• Moderate: Intermediate symptoms and harm (stealing without confronting victim, vandalism)
• Severe: Many conduct problems, considerable harm (forced sex, physical cruelty, weapon use, breaking and entering)

5. CLINICAL FEATURES AND DIAGNOSIS

• Overt aggression: Bullying, fighting, physical cruelty
• Covert behaviors: Lying, stealing, deceit - these are harder to treat than overt symptoms
• Rule violations: Truancy, running away, staying out late
• Fire-setting (particularly noted in younger boys with the disorder)

6. ETIOLOGY

• Harsh, punitive parenting with severe physical/verbal aggression is a major risk factor
• Parental psychopathology (antisocial personality disorder, alcohol use disorder, substance use disorder)
• Parental negligence, lack of supervision, chaotic home conditions
• Divorce per se is not the risk factor - rather, persistent parental hostility and conflict post-divorce

• Twin studies show genetic and environmental factors contribute approximately equally in males and females
• Possible role for the X-linked monoamine oxidase A (MAOA) gene in antisocial behavior
• Children of parents with ASPD and alcohol use disorder are at higher risk

• Youth in population-dense areas have higher rates of aggression and delinquency
• Unemployment, lack of social network, lack of community participation
• Substance use - weekly alcohol use in adolescents is associated with delinquent and aggressive behavior
• Drug intoxication can aggravate symptoms

• Longitudinal studies show exposure to media violence (including video gaming) correlates with aggression in adolescents
• Violent video game playing is related to aggressive affect, physiologic arousal, and aggressive behavior

• Poor emotion regulation is strongly associated with conduct disorder
• Emotion dysregulation is observable in preschool children - those with greater dysregulation exhibit higher aggression
• Poor impulse control modeling

• Neuroimaging (MRI): Children with CD show decreased gray matter in limbic structures, bilateral anterior insula, and left amygdala compared to controls
• Neurotransmitters:
  • Low plasma dopamine-β-hydroxylase (enzyme converting dopamine to norepinephrine) - suggests decreased noradrenergic functioning
  • High plasma serotonin in conduct-disordered juvenile offenders
  • Low 5-HIAA in CSF correlates with aggression and violence (serotonin hypothesis)
• EEG: Aggressive children show higher right frontal brain activity at rest, reflecting poor emotional regulation

• Chronic exposure to violence, physical/sexual abuse, and neglect - especially at a young age - strongly predicts aggression
• Children exposed to intimate partner violence show strong association with offspring aggression
• Severely abused children become hypervigilant and misperceive benign situations as threatening, responding with violence

7. COMORBIDITY

• ADHD is the most common comorbidity - ADHD often predates conduct disorder; together they increase risk for substance abuse
• CNS injury, dysfunction, or damage predisposes to impulsivity and conduct disorder
• Learning disorders commonly associated and often predate the diagnosis
• Substance use disorders - more common in individuals with conduct disorder
• Mood disorders, depression, and bipolar disorder can co-occur

8. DIFFERENTIAL DIAGNOSIS

An isolated act of aggressive behavior does NOT justify a diagnosis of conduct disorder - an entrenched pattern must be present.

9. COURSE AND PROGNOSIS

• Young age of onset (childhood-onset type)
• High number of symptoms
• Severe symptoms
• Presence of LPE specifier
• Comorbid psychopathology (ADHD, mood disorders, substance use)
• Parental criminality and assaultive behavior in childhood predict later incarceration

• Mild symptoms
• No coexisting psychopathology
• Normal intellectual functioning
• Adolescent-onset type (better prognosis than childhood-onset)

• A significant proportion of childhood-onset cases progress to Adult Antisocial Personality Disorder
• Some patients develop mood disorders and substance use disorders in adulthood
• Note: the diagnosis of CD alone does not directly correlate with imprisonment; it is assaultive behavior + parental criminality that best predicts incarceration

CONDUCT DISORDER - QUESTION 2 (20 Marks): TREATMENT

TREATMENT OF CONDUCT DISORDER

1. OVERVIEW / GENERAL PRINCIPLES

2. PSYCHOSOCIAL INTERVENTIONS

A. Preventive Interventions (Early)

• The Fast Track Preventive Intervention randomized 891 kindergarteners to either a 10-year prevention program or a control condition
• The 10-year intervention included: parent behavior management, child social cognitive skills training, reading support, home visiting, mentoring, and classroom curricula
• Children in the Fast Track program were significantly less likely to develop conduct disorder during those 10 years and for 2 years beyond

B. Cognitive-Behavioral Therapy (CBT)

1. Kazdin's Problem-Solving Skills Training (PSST):
   • 12-week sequential program
   • Helps children develop problem-solving strategies in conflictual situations
   • Uses "supersolvers" - vignette assignments for practice
   • Can be combined with Parent Management Training (PMT) but is effective alone
2. The Incredible Years (IY):
   • Targets children aged 3-8 years
   • Administered over 22 weeks
   • Delivers sessions to child, parents (parent training component), and teachers (teacher training)
3. Anger Coping Program:
   • An 18-session intervention for school-age children in grades 4-6
   • Focused on emotion recognition, emotion regulation, and managing anger
   • Strategies include: distraction, self-talk, perspective-taking, goal setting, problem-solving
4. Making Choices (MC) - Social Problem Solving Skills for Children:
   • School-based intervention
   • Reduces overt and social aggression, increases social competence
   • Improves information-processing skills

Note: Treatment programs are more successful in reducing overt symptoms (aggression, fighting) than covert symptoms (lying, stealing).

3. FAMILY THERAPY

• Establish warm, mutually respectful parent-child relationships
• Address coercive negative cycles between parent and child
• Strengthen parental supervisory and limit-setting abilities

A. Parent-Child Interaction Therapy (PCIT)

• Designed for preschool children (ages 2-6) with ODD/early conduct problems
• Focuses on building positive aspects of the parent-child relationship
• Therapist praises the parent, the parent then extends that warmth to the child - creating closeness and attunement
• Leads to improved cooperation and compliance in the child
• Evidence base: shown effective in over 30 clinical trials
• Also used by child protective services in cases of mild physical abuse

B. Multisystemic Therapy (MST)

• Designed for adolescents with delinquency involved with the juvenile justice system
• Intensive model: 3-4 contacts weekly, over 4 months
• Trained therapists with very small caseloads
• Addresses all systems: family, school, peer, and community
• Helps parents manage stress, supervise, and set limits
• Child earns privileges by responding to parental direction
• Rules and consequences defined early; parental availability and consistency are paramount
• Evidence: Shown effective in reducing recidivism and delinquency in multiple treatment trials
• Best suited for moderate delinquency, particularly early in the course

C. Parent Management Training (PMT)

• Parents attend sessions without the child
• Learn and practice techniques of setting limits and imposing consequences
• Key focus: helping parents plan how to withstand the child's demanding/defiant behavior and how to respond if behavior worsens before improving
• Builds united front among adult authority figures and mutual support
• Parental self-control is a key goal

4. SCHOOL-BASED INTERVENTIONS

• Behavioral techniques can promote socially acceptable peer behavior and discourage covert antisocial incidents
• School curricula targeting social problem-solving (e.g., Making Choices program) reduce aggression and improve social competence
• Teacher training components (as in IY) help manage classroom behavior

5. PSYCHOPHARMACOLOGICAL INTERVENTIONS

A. Antipsychotics (for Aggression)

• Haloperidol - early studies reported decreased aggressive and assaultive behaviors; now largely replaced by atypicals due to side effects

• Sedation
• Increased prolactin levels (especially risperidone)
• Extrapyramidal symptoms (akathisia)
• Generally well tolerated overall

B. Mood Stabilizers

C. Alpha-2 Agonists

• Clonidine: A pilot study found it may decrease aggression
• Particularly useful when conduct disorder is comorbid with ADHD

D. Stimulants

• Used when ADHD is comorbid with conduct disorder (very common)
• Methylphenidate and other stimulants treat the ADHD component, indirectly reducing impulsive aggression
• Must be monitored carefully given risk of misuse

E. Selective Serotonin Reuptake Inhibitors (SSRIs)

• Used clinically for impulsivity, irritability, and mood lability that frequently accompany conduct disorder
• Agents: fluoxetine, sertraline, paroxetine, citalopram
• Especially useful when comorbid depression or anxiety is present

6. RESIDENTIAL TREATMENT AND JUVENILE JUSTICE CONSIDERATIONS

• For severe cases where outpatient management fails, residential treatment or involvement of the juvenile justice system may be necessary
• Family therapy helps parents avoid prematurely externalizing the problem as residing solely in the child ("placing" the child)
• MST is specifically designed to bridge the gap between mental health and juvenile justice systems

7. TREATMENT OF COMORBIDITIES

8. PROGNOSIS OF TREATMENT

• Early intervention is key - prevention at kindergarten age gives the best outcomes
• Treatment programs more successfully reduce overt aggression than covert behaviors (lying, stealing)
• Mild CD with normal intelligence and no comorbidities responds best
• Childhood-onset with LPE specifier has the poorest response to treatment
• MST shows durable reductions in recidivism for adolescents with delinquency when applied early in the course

SUMMARY TABLE: Treatment of Conduct Disorder