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
Possible risk factors :
Complications :
Associated conditions :
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) :
- consisder comoribd conditions ( 1 )
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) :
General Physical :
- no specific findings on physical exam
- check for signs of substance abuse ( 1 )
- assess for suicidal thoughts ( 1 )
Making the diagnosis :
Rule out :
Testing to consider :
- urine or blood screening for drug use ( 1 )
Prognosis :
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 :
- 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
General references used :
Reviews :
Guidelines :
Patient information :
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