Conduct Disorder

What Causes Conduct Disorder?

The cause of CD is not yet known. It’s likely caused by a combination of genetic, biological, and environmental factors. Some possible factors that increase the risk of a child developing CD include:

• Brain damage for injury or illness
• Emotional trauma
• Dysfunctional home environment
• Family history of mental illness
• Learning disabilities
• Substance abuse
• Personal history of mental illness

Is Conduct Disorder Hereditary?

Children with a family history of mental illness are more likely to have CD, suggesting that the disorder may have a genetic component. However, no specific gene or genes have yet been associated with CD. The condition could likely be caused by a combination of genetic predisposition and environmental factors.

How Is Conduct Disorder Detected?

CD is typically diagnosed in childhood or adolescence, but symptoms are likely to continue into adulthood. Warning signs of CD in children and adolescents can include:

• Failure to follow rules at home or school
• Destruction of property
• Stealing
• Lying
• Cruelty or lack of empathy toward others

How Is Conduct Disorder Diagnosed?

Diagnosis of CD begins with determining that the patient has a cluster of symptoms that meet the diagnostic criteria for the disorder. A doctor will start with a physical exam to rule out biological problems that may be causing symptoms. After these exams, if the doctor suspects that CD or another mental disorder is the cause of the symptoms, they may recommend a psychological or psychiatric assessment to solidify the diagnosis further.

Diagnostic steps may include:

• A physical exam. This exam will rule out physical conditions that could be causing the symptoms.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

The results of the psychological assessments will be compared to the diagnostic criteria for CD in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria for CD include:

• The child exhibits at least three symptoms from four categories: aggression toward people and/or animals, destruction of property, deceitfulness or theft, and serious violations of rules.
• A minimum of three symptoms have occurred in the past 12 months, and at least one of the symptoms has happened in the past six months.
• The symptoms cause significant impairment in function.
• In people over 18, the symptoms don’t meet the diagnostic criteria for antisocial personality disorder.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Conduct Disorder Treated?

There is no cure for CD. However, early intervention may help to control the disorder’s symptoms and prevent future complications. Psychotherapy is the most common course of treatment. In addition, medications may reduce symptoms of other co-existing disorders, such as ADHD or anxiety.

Types of therapy commonly used to treat CD include:

• Cognitive-behavioral therapy
• Family therapy
• Peer group therapy
• Parent training
• Social skills training

How Does Conduct Disorder Progress?

Without treatment, CD sometimes evolves into antisocial personality disorder (ASPD) in adults. The symptoms of ASPD are very similar to those of CD, but the personality disorder can’t be diagnosed in children. Therefore, children with CD whose symptoms continue into adulthood are often later diagnosed with ASPD.

Long-term adverse effects of these disorders can include:

• Domestic violence
• Child abuse
• Sexual abuse
• Unemployment
• Homelessness
• Alcohol or substance abuse
• Homicide
• Incarceration
• Depression
• Anxiety
• Injury or death as a result of violent or impulsive behavior
• Suicide

How Is Conduct Disorder Prevented?

Given that the cause of CD is unclear, no definitive strategy for prevention is known. However, early intervention when a young child shows symptoms of CD can help prevent worse problems in the future.  Unfortunately, many children with CD don’t get treatment because their behavioral issues are interpreted as criminal behavior rather than mental illness. In all cases, parent involvement and training are essential for helping children cope with CD.

Conduct Disorder Caregiver Tips

Many people with conduct disorder also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with CD:

• Many people with CD also have attention-deficit/hyperactivity disorder (ADHD).
• Many people with CD also suffer from depression or anxiety disorders. These disorders are especially common in adolescents with CD.
• Alcoholism and substance abuse are frequently co-morbid with CD.
• People with CD are at increased risk of developing other behavioral disorders such as antisocial personality disorder.

Conduct Disorder Brain Science

Researchers have attempted to find neurological explanations for problematic behaviors in people with conduct disorder and the similar oppositional defiant disorder (ODD). Studies have found some differences in the way the brains of people with these disorders function in comparison to healthy brains. The key differences seem to lie in three different areas, including:

• The brains of people with CD show a reduced reaction to negative stimuli, stress, and fear, which might suggest that they do not respond normally to punishment.
• Their brains have lower than expected activity in the areas involved in processing incentives, suggesting that they are not as likely to be motivated by rewards.
• They showed impairment in the parts of the brain that control executive function. These areas help people gain rational control over their emotions, an ability that might be limited in people with CD.

Conduct Disorder Research

Title: Addressing Depression and Positive Parenting Techniques (ADAPT) (ADAPT)

Stage: Not Yet Recruiting

Principal investigator: Brendan F. Andrade, PhD

Centre for Addiction and Mental Health

Toronto, Ontario

Children with emotional and behavioral difficulties (EBD) experience disproportionate social, family, and academic impairment and have a two to five times increased likelihood of developing an anxiety disorder, mood disorder, or other severe mental illness in adolescence and adulthood. There is a close association between parental depression and the emergence and maintenance of childhood EBD that is likely bidirectional. Parents of children with EBD experience disproportionate stress, increasing their risk for depression; yet chronic and untreated parental depression is associated with the emergence of child EBD in the first place. Therefore, designing targeted and effective assessment and treatment for parents of children with EBD that consider the parents’ depression is necessary. Of pressing concern, first-line Behavioral Parent Training (BPT) treatments for parents of children with EBD are not tailored to parents’ mental health needs, which may be why upwards of 40 percent of parents and children treated in these programs fail to sufficiently benefit. Existing research highlights emotional and cognitive factors that may differentiate depressed parents from non-depressed parents that may be treatment targets to improve outcomes for depressed parents and children.

The main aim of the proposed project is to evaluate the feasibility and acceptability of a novel targeted treatment for depressed parents of children with EBD, along with adherence to study protocol. The investigators will use the pilot study results to make key modifications to study procedures and the treatment itself to increase the success of a future randomized controlled trial (RCT) to test treatment efficacy.

Title: Virtual Reality to Improve Social Perspective Taking

Stage: Recruiting

Principal investigator: Tom A. Hummer, PhD

Indiana University School of Medicine

Indianapolis, IN 

Oppositional defiant disorder (ODD) and conduct disorder (CD), collectively known as disruptive behavior disorders (DBDs), involve persistent physical or verbal confrontations, antisocial behavior, and emotional outbursts. Despite a range of biological and environmental risk factors for DBD, social-cognitive impairments are a common link, and improving these deficits should be beneficial for all patients with DBD.

Children and adolescents with DBD have deficits in social perspective-taking that contribute significantly to these behavior problems. Perspective-taking is the ability to perceive the world from another person’s point of view, including making inferences about the capabilities, feelings, and expectations of others. Perspective-taking requires substantial motivation and cognitive resources and can be challenging to achieve, particularly for children. A failure to understand or value another person’s perspective inhibits helping behavior without clear, direct benefits. Perspective-taking skills are related to empathic concern, which encompasses feelings of sympathy and concern for unfortunate others, and theory of mind, the ability to infer others’ mental states, such as intentions accurately. Negative attribution biases are more likely in individuals with poor theory of mind. Thus, improving children’s perspective-taking skills should allow them to understand a counterpart’s thinking and intentions better, increasing empathic concern and reducing hostile attribution biases-and, therefore, improving the likelihood that prosocial behavior occurs.

In the brain, perspective-taking engages circuitry underlying empathic concern and theory of mind. In fMRI studies, imagining pain to the self or other, often in conjunction with images depicting painful scenarios, engages the brain’s salience network. Dorsal ACC and bilateral anterior insula, the regions most commonly activated in response to others’ pain, also show strong responses to self-perspective pain. However, in youth with DBD, there is a decreased response to other-perspective pain in dACC and anterior insula, despite no change or a heightened response to self-perspective pain.

Software interventions have shown some promise to improve perspective-taking. In particular, VR has exciting therapeutic potential to address perspective-taking deficits because it provides naturalistic yet controlled environments where users can experience interactions from multiple viewpoints. VR interventions typically provide a better generalization to real-world behavioral changes compared to traditional methods. VR has an advantage over traditional interventions because it provides an embodied experience that is a middle ground between therapy room settings and the real world (e.g., school, home) where problematic behaviors occur.

The investigators will build upon a current VR design using an Oculus Quest virtual reality headset in this investigation. After experiencing virtual interpersonal conflicts in a school cafeteria setting, participants will re-experience scenarios in one of two manners: an enriched perspective from the virtual counterpart’s point-of-view, with internal dialogue and background information; or a control perspective, which replays the original point-of-view. During this proof-of-concept phase, the primary target is social perspective-taking. The investigators will assess the functional engagement of this target by quantifying (1) the ability to recognize and understand the virtual counterpart’s perspective; and (2) the neural response (in pain circuitry) to pain experienced by the virtual counterpart, a common marker for perspective-taking that is abnormal in DBD.

Title: SKIP for PA Study: Team and Leadership Level Implementation Support for Collaborative Care (SKIPforPA)

Stage: Not Yet Recruiting

Principal Investigator: Renee M. Turchi, MD, MPH

Drexel University

Philadelphia, PA 

This study is a randomized, hybrid type 3 effectiveness-implementation trial to support the adoption of a chronic care model (CCM)-based intervention in pediatric primary care settings by testing the impact of implementation strategies directed towards the provider care team (TEAM) or practice leadership (LEAD) level. The treatment investigators seek to deliver is Doctor Office Collaborative Care (DOCC), an evidence-based intervention for managing child behavior problems and co-morbid ADHD. The implementation strategies being tested to enhance DOCC uptake include TEAM coaching/consultation strategies, which will be delivered to care team providers and target provider competency to deliver DOCC, and LEAD facilitation strategies, which will be delivered to practice leaders and target organizational support of DOCC delivery. These multi-level implementation strategies have not been formally evaluated to learn about their separate and combined effects in any randomized clinical trial conducted in pediatric primary care. Such information is needed to optimize our approaches to promoting the implementation of a CCM-based intervention in pediatric practice.

The statewide sample includes 24 primary care practices from the Medical Home Program of the Pennsylvania Chapter of the American Academy of Pediatrics. After standard training in the DOCC EBP, all practices will be randomized to one of four implementation conditions: 1) No TEAM or LEAD (ongoing technical support only); 2) TEAM implementation; 3) LEAD implementation, or 4) TEAM+LEAD implementation. TEAM and LEAD implementation will be delivered via videoconference (or possibly in person) on a graded schedule. Care teams will deliver DOCC to 25 children who meet a clinical cutoff for modest behavior problems and their caregivers. Investigators will collect practice/provider measures from enrolled practice staff (0, 6, 12, 18, 24 months) and caregivers over several time points (0, 3, 6, 12 months) to support all analyses evaluating implementation and treatment outcomes, mediation, and moderation. By proposing one of the first large pragmatic pediatric trials of a CCM-based evidence-based intervention to address these aims in response to RFA-MH-18-701 and the NIMH’s Strategic Plan (4.2), this research will advance the implementation science knowledge needed to optimize promising strategies for promoting the delivery and scale-up of DOCC in a pediatric medical home.