General Information (including ICD-9/-10 Codes)

Description :

  • disruptive behavior disorder in childhood and adolescence ( 2 )

ICD-9 Codes :

  • 312.0 undersocialized conduct disorder, aggressive type
    • 312.00 undersocialized conduct disorder, aggressive type, unspecified degree
    • 312.01 undersocialized conduct disorder, aggressive type, mild degree
    • 312.02 undersocialized conduct disorder, aggressive type, moderate degree
    • 312.03 undersocialized conduct disorder, aggressive type, severe degree
  • 312.1 undersocialized conduct disorder, unaggressive type
    • 312.10 undersocialized conduct disorder, unaggressive type, unspecified degree
    • 312.11 undersocialized conduct disorder, unaggressive type, mild degree
    • 312.12 undersocialized conduct disorder, unaggressive type, moderate degree
    • 312.13 undersocialized conduct disorder, unaggressive type, severe degree
  • 312.2 socialized conduct disorder
    • 312.20 socialized conduct disorder, unspecified degree
    • 312.21 socialized conduct disorder, mild degree
    • 312.22 socialized conduct disorder, moderate degree
    • 312.23 socialized conduct disorder, severe degree
  • 312.3 disorders of impulse control, not elsewhere classified
    • 312.30 impulse control disorder, unspecified
    • 312.31 pathological gambling
    • 312.32 kleptomania
    • 312.33 pyromania
    • 312.34 intermittent explosive disorder
    • 312.35 isolated explosive disorder
    • 312.39 other disorders of impulse control
  • 312.4 mixed disturbance of conduct and emotions
  • 312.8 other specified disturbances of conduct, not elsewhere classified
    • 312.81 conduct disorder, childhood onset type
    • 312.82 conduct disorder, adolescent onset type
    • 312.89 other specified conduct disorder, not elsewhere classified
  • 312.9 unspecified disturbance of conduct

ICD-10 Codes :

  • F90.1 hyperkinetic conduct disorder
  • F91 conduct disorders
    • F91.0 conduct disorder confined to the family context
    • F91.1 unsocialized conduct disorder
    • F91.2 socialized conduct disorder
    • F91.3 oppositional defiant disorder
    • F91.8 other conduct disorders
    • F91.9 conduct disorder, unspecified
  • F92 mixed disorders of conduct and emotions
    • F92.0 depressive conduct disorder
    • F92.8 other mixed disorders of conduct and emotions
    • F92.9 mixed disorder of conduct and emotions, unspecified

Types :

  • childhood-onset (at least one criterion  occuring before age 10 years ( 1 )
  • adolescent-onset (after age 10 years) ( 1 )
  • various approaches to subtyping ( 1 )
    • overt vs. covert vs. authority-conflicted subtypes
    • underrestrained vs. overrestrained subtypes
    • socialized vs. undersocialized subtypes
  • "childhood-limited" subtype with better prognosis proposed for DSM-V (J Child Psychol Psychiatry. 2008 Jan;49(1):3)

Who is most affected :

Incidence/Prevalence :

  • 1.5-3.4% prevalence in general population of children and adolescents based on clincial interviewing ( 1 )
  • estimated 9.5% lifetime prevalence reported in United States
    • based on face-to-face household survey of 9,282 adults
    • among those who responded and met criteria for at least one mental disorder, 3,199 participants aged 18-44 years were evaluated for conduct disorder
    • estimated lifetime prevalence 12% in males and 7.1% in females
    • Reference - Psychol Med 2006 May;36(5):699 full-text

Causes and Risk Factors

Possible risk factors :

Complications and Associated Conditions

Complications :

Associated conditions :

History

Chief Concern (CC) :

  • aggression or serious threats of harm to people or animals ( 2 )
  • deliberate property damage or destruction ( 2 )
  • repeated violation of household or school rules or laws ( 2 )
  • persistent lying ( 2 )
    • avoiding consequences
    • obtaining goods or privileges

History of Present Illness (HPI) :

  • for diagnostic assessment, evaluator should interview patient, teachers, and parents separately and together ( 1 )
  • consider history of sexual abuse, either as victim or perpertrator ( 1 )
  • may have early history of irritability, inconsolability, impaired social skills ( 2 )
  • parental concern of behavioral problems associated with conduct disorder
    • based on survey of 10,438 children aged 5-15 years in Great Britain
    • 5.5% had parental concern of behavioral problems
    • 4.8% had conduct disorder based on DSM-IV criteria
    • for predicting conduct disorder, parental concern of behavioral problems had
      • 53% sensitivity
      • 96.9% specificity
      • 46.5% positive predictive value
      • 97.6% negative predictive value
    • Reference - BMJ 2005 Dec 17;351(7530):1435 full-text

Past Medical History (PMH) :

Family History (FH) :

  • antisocial behavior in family members may include ( 1 )
    • violence
    • physical or sexual abuse
    • incarceration
    • substance abuse
    • mood disorders
    • personality disorders

Social History (SH) :

Physical

General Physical :

  • no specific findings on physical exam
  • check for signs of substance abuse ( 1 )
  • assess for suicidal thoughts ( 1 )

Diagnosis

Making the diagnosis :

Rule out :

Testing to consider :

  • urine or blood screening for drug use ( 1 )

Prognosis

Prognosis :

Treatment

Counseling :

  • parent training/education programs appear effective and possibly cost-effective for children with conduct disorder (level 2 [mid-level] evidence)
    • systematic review of 37 randomized trials
    • many trials had poor quality, trials were clinically heterogeneous
    • intervention had consistent trend towards short-term effectiveness up to 4 months in child behavior
    • few significant differences between parent training/education programs but trend for more intensive interventions to be more effective
    • high cost but potentially cost-effective when accounting for cost of criminality
    • Reference - Health Technol Assess 2005 Dec;9(50):iii PDF
  • family and parenting interventions for juvenile delinquents and their families have beneficial effects on reducing time spent in institutions
    • systematic review of 8 trials with 749 children ages 10-17 years with conduct disorder or delinquency and their families randomized to family and parenting intervention vs. control group
    • 7 trials of delinquents and 1 trial of conduct disorder
    • Reference - systematic review last updated 2001 Feb 28 (Cochrane Library 2001 Issue 2:CD003015)
  • parenting groups may reduce serious antisocial behavior in children in real life conditions
    • 141 children ages 3-8 years with antisocial behavior (most had conduct disorder) were randomized to parenting groups vs. wait list control
    • parenting groups consisted of parents of 6-8 children and met for 2 hours each week for 13-16 weeks and covered play, praise and rewards, limit setting, and handling misbehavior
    • mean attendance 9 sessions
    • ratio of praise to inappropriate commands increased in parenting group and decreased in control group
    • intervention led to statistically significant reductions in antisocial behavior, no change in control group
    • Reference - BMJ 2001 Jul 28;323(7306):194 PDF

Medications :

  • pharmacologic management alone insufficient ( 2 )
  • addition of fluoxetine to cognitive behavioral therapy may be ineffective in adolescents with depression, conduct disorder and substance use disorder (level 2 [mid-level] evidence)
    • based on randomized trial with mixed results
    • 126 adolescents aged 13-19 years with current major depressive disorder, conduct disorder and non-tobacco substance use disorder who were starting treatment with cognitive behavioral therapy were randomized to fluoxetine 20 mg/day vs. placebo for 16 weeks
    • no significant differences in
      • Clinical Global Impression Improvement treatment response
      • self-reported drug use in past 30 days
      • self-reported conduct disorder symptoms
      • treatment completion rates
    • fluoxetine associated with significant differences in
      • greater efficacy in Childhood Depression Rating Scale-Revised scores
      • lower proportion of negative weekly urine drug screen results
    • Reference - Arch Pediatr Adolesc Med 2007 Nov;161(11):1026 full-text
  • lithium may be helpful for severe and persistent aggression (level 2 [mid-level] evidence)
    • 86 inpatients aged 10-17 years with at least 3 aggressive acts per week (including at least 2 physically aggressive acts) randomized to lithium (final doses 900-2,100 mg/day for steady state level of 0.78-1.55 mmol/L [0.78-1.55 mEq]) vs. placebo orally 3 times daily for 4 weeks
    • only 40 (46.5%) completed treatment of whom 80% vs. 30% were responders on consensus ratings (p = 0.004)
    • > 50% lithium patients had side effects of nausea, vomiting, urinary frequency
    • Reference - Arch Gen Psychiatry 2000 Jul;57(7):649 in Pediatric Notes 2000 Jul 20;24(29):116
  • risperidone may be helpful for children with disruptive behavior disorders (level 2 [mid-level] evidence)
    • 100 children 5-12 years old with sub-average IQ (35-84) and conduct disorder, oppositional defiant disorder or disruptive behavior not otherwise specified underwent 1-week placebo run-in and were then randomized to risperidone 0.02-0.06 mg/kg/day vs. placebo for 6 weeks
    • statistically significant differences in disruptive behaviors were seen at 1 week and throughout the trial
    • risperidone also improved irritability, lethargy/social withdrawal, stereotyped behavior and hyperactivity
    • 41.5% vs. 14% somnolence (NNH 3), 17% vs. 7% headache (NNH 10), 15.1% vs. 3.5% increased appetite (NNH 8), 11.3% vs. 0 hyperprolactinemia (NNH 8)
    • Reference - Annual Meeting of the Canadian Pediatric Society 2001 Jun 13-17 in Pediatric Notes 2001 Jun 28;25(26):102
    • risperidone maintained efficacy for 48 weeks in open-label extension study of 77 patients following this trial; 76 patients had adverse effects including somnolence (52%), headache (38%), and weight gain (36%) (Pediatrics 2002 Sep;110(3):e34 full-text), commentary can be found in Pediatrics 2004 Feb;113(2):421 full-text
  • clonidine may reduce conduct problems in children with ADHD and conduct disorder or oppositional defiant disorder (level 2 [mid-level] evidence)
    • 67 children aged 6-14 years with ADHD and oppositional defiant disorder or conduct disorder who had received psychostimulant for at least 3 months were randomized to clonidine 0.5 mg twice daily (increased to 1 mg twice daily after 1 week, but morning dose decreased to 0.5 mg if excessive sedation) vs. placebo for 6 weeks, stimulants continued
    • 57% clonidine vs. 21% placebo group improved by > 37% on conduct scale (NNT 3)
    • Reference - J Am Acad Child Adolesc Psychiatry 2003 Aug;42(8):886 in QuickScan Reviews in Fam Pract 2004 Jan 2;29(5):17
  • other medications which have been used for conduct disorder include ( 2 )

Other management :

  • written or video-based materials to convey behavioral skills to parents may contribute to improvements in child behavior (level 2 [mid-level] evidence)
    • systematic review of 11 randomized and quasi-randomized trials of media-based behavioral treatments for behavior problems in 943 children
    • 7 trials included children with conduct problems, 2 trials included learning-disabled children, 1 trial inlcuded children with ADHD, 1 trial included sleep problems; all trials included children within age range 2-14 years
    • 8 trials evaluated written information to convey behavioral skills to parents, 3 trials used video modelling of behavioral techniques
    • media-based therapies for behavioral disorders in children had moderate, if variable, effect
    • significant improvements were made with addition of up to 2 hours of therapist time
    • Reference - systematic review last updated 2005 Sep 26 (Cochrane Library 2006 Issue 1:CD002206)
  • insufficient evidence to support or refute use of MultiSystemic Therapy (intensive, home-based intervention) for families of youth (ages 10-17 years) with social, emotional, and behavioral problems; systematic review of 8 studies last updated 2005 Aug 23 (Cochrane Library 2005 Issue 4:CD004797)

Prevention and Screening

Prevention :

  • Sure Start parenting intervention may reduce problem behaviors in young children at risk of conduct disorder (level 2 [mid-level] evidence)
    • based on unblinded randomized trial with differential loss to follow-up
    • 153 parents from socially disadvantaged areas in Wales with children ages 36-59 months at risk of conduct disorder were randomized to intervention vs. wait-list control
    • intervention was group based intervention called Webster-Stratton Incredible Years basic parenting program, groups of up to 12 parents met for 2-2.5 hours weekly for 12 weeks
    • comparing intervention vs. control
      • 104 vs. 49 families randomized in initial 2:1 randomization
      • 86 (83%) vs. 47 (96%) completed the trial
      • 73 (70%) vs. 43 (88%) analyzed for cost-effectiveness
      • mean change in Eyberg child behavior inventory -5.8 vs. -1 points
      • mean change in Eyberg child behavior intensity -24.5 vs. +2.7 points
    • Reference - BMJ 2007 Mar 31;334(7595):678 PDF, editorial can be found in BMJ 2007 Mar 31;334(7595):646 full-text, correction can be found in BMJ 2007 Apr 28;334(7599)
    • intervention considered cost-effective (BMJ 2007 Mar 31;334(7595):682 PDF), editorial can be found in BMJ 2007 Mar 31;334(7595):646 full-text
  • early preventive intervention for disruptive boys in kindergarten associated with increased high school graduation rate and decreased criminal behavior (level 2 [mid-level] evidence)
    • based on 15-year follow-up of randomized trial with low participation rate
    • 250 boys with backgrounds of low socioeconomic status and high disruptiveness scores on ratings by kindergarten teachers were randomized to multi-component preventive intervention (aimed at boys, parents and teachers) vs. attention-control vs. no-contact control for 2 years
    • preventive intervention program included
      • social skills training aimed at promoting changes in behavior towards peers
      • parent training in effective child-rearing
      • information and support provided to teachers
    • 172 families (69%) agreed to participate in intervention, but all 250 at-risk boys included in intention-to-treat analysis
    • no differences found for any outcome comparing attention-control vs. control, so 2 control groups were combined for analyses
    • comparing intervention vs. control
      • 45.6% vs. 32.2% graduated from high school (p < 0.05, NNT 8)
      • 21.7% vs. 32.6% had criminal record (p = 0.06, NNT 9)
    • Reference - Br J Psychiatry 2007 Nov;191:415
  • 10-year school-level intervention begun in kindgerarten might decrease antisocial behavior in high-risk children (level 2 [mid-level] evidence)
    • based on subgroup analysis of cluster-randomized trial
    • 891 children (mean age 6.5 years) at high or moderate risk for antisocial behavior were randomized by matched sets of schools to intervention vs. control
    • intervention during grades 1-9 consisted of parent behavior-management training, child social-cognitive skills training, reading tutoring, home visiting, mentoring, and universal classroom curriculum
    • 142 (16%) children were high-risk (defined as top 3% of normative population), 84% were moderate-risk
    • no significant differences in moderate risk group in rates of any psychiatric diagnosis
    • rates of any psychiatric diagnosis at grade 3 comparing intervention vs. control in high-risk children
      • any psychiatric diagnosis in 38% vs. 53% (p < 0.05, NNT 7)
      • oppositional defiant disorder in 14% vs. 31% (p < 0.01, NNT 6)
      • conduct disorder in 11% vs. 20% (p < 0.1)
      • attention-deficit disorder in 34% vs. 44% (not significant)
    • no significant differences in any psychiatric diagnosis at grade 6 in high-risk children
    • rates of any psychiatric diagnosis at grade 9 comparing intervention vs. control in high-risk children
      • any psychiatric diagnosis in 26% vs. 46% (p < 0.05, NNT 5)
      • conduct disorder in 5% vs. 21% (p < 0.05, NNT 7)
      • attention-deficit hyperactivity disorder in 16% vs. 34% (p < 0.05, NNT 6)
      • oppositional defiant disorder in 16% vs. 28% (not significant)
    • Reference - J Am Acad Child Adolesc Psychiatry 2007 Oct;46(10):1250

References including Reviews and Guidelines

General references used :

Reviews :

Guidelines :

Patient Information

Patient information :