Summary

Conduct disorder (CD) is a childhood-onset psychiatric condition characterised by a repetitive and persistent pattern of behaviour that violates the basic rights of others or major age-appropriate societal norms and rules. Core features include aggression towards people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. It is closely related to Oppositional Defiant Disorder (ODD), which is often considered a less severe precursor. CD is a significant risk factor for the development of Antisocial Personality Disorder (ASPD) in adulthood. The presence of callous-unemotional (CU) traits (lack of guilt, reduced empathy) indicates a more severe subtype with poorer prognosis. Management is primarily psychological, focusing on parent training programmes, multi-systemic therapy (MST), and addressing comorbidities.

Key Facts

• Prevalence: 3-5% of children; higher in boys (3:1 ratio)
• Onset: Childhood-onset (<10 years) has worse prognosis than adolescent-onset
• ODD vs CD: ODD is less severe (no aggression to people/animals, no destruction of property); CD is more severe
• Callous-Unemotional (CU) traits: Lack of guilt/remorse; poor empathy; poor prognosis; DSM-5 specifier
• Progression: ODD → CD → Antisocial Personality Disorder (pathway, not inevitable)
• Comorbidities: ADHD (~50%), substance misuse, depression, learning difficulties
• Management: Parent training (e.g., Webster-Stratton), Multi-Systemic Therapy (MST)
• Prognosis: Childhood-onset with CU traits has worst outcome; adolescent-onset often improves

Clinical Pearls

"The Triad of Fire-Setting, Bedwetting, Cruelty to Animals": Historically called the MacDonald triad, these behaviours in childhood were thought to predict violent behaviour. While not diagnostic, cruelty to animals and fire-setting are serious warning signs requiring urgent assessment.

"ODD Is Not Just a Naughty Child": ODD involves a pattern of angry, irritable mood and defiant behaviour lasting at least 6 months. It is a clinical diagnosis, not just normal childhood misbehaviour.

"Callous-Unemotional = High Risk": Children with CU traits (lack of guilt, shallow affect, unconcern about performance, reduced empathy) have poorer response to treatment and are at higher risk of adult antisocial behaviour.

"Parent Training First": NICE recommends parent training programmes as first-line for children under 12. These focus on positive parenting strategies, limit-setting, and improving the parent-child relationship.

"Multi-Systemic Therapy for Severe Cases": MST is an evidence-based intensive family and community-based treatment for adolescents with severe conduct problems. It addresses family, peer, school, and community factors.

Why This Matters Clinically

Conduct disorder is one of the most common reasons for child and adolescent mental health referral. Early identification and intervention can alter the trajectory towards ASPD and reduce long-term criminal justice involvement, substance misuse, and mental health problems. Recognising comorbidities (especially ADHD) and the presence of CU traits is essential for appropriate management and prognostication.[1,2]

Mental State Examination (MSE)

Assessment Domains

Prognostic Factors

Outcomes by Onset Type

Key Guidelines

Key Research

Webster-Stratton Parenting Programmes

• Multiple RCTs show effectiveness in reducing conduct problems
• Improves parent-child interaction
• NNT ~3-5 for clinically significant improvement
• PMID: 23165355

Multi-Systemic Therapy (MST)

• RCTs show reduced re-arrest rates and out-of-home placements
• Intensive but cost-effective
• PMID: 16803502

What is Conduct Disorder?

Conduct disorder is a condition where a young person repeatedly behaves in ways that break rules, hurt others, or damage property. It's more than just being "naughty" — it's a pattern of behaviour that causes real problems at home, school, or in the community.

What are the signs?

Signs include:

• Getting into a lot of fights
• Bullying or being cruel to people or animals
• Destroying property or stealing
• Running away from home or skipping school frequently
• Lying often or breaking serious rules

What causes it?

There's no single cause. It's usually a combination of:

• Genetics
• Difficult family situations (harsh parenting, conflict)
• Problems at school
• Influence from peers who also misbehave

How is it treated?

Treatment focuses on:

• Parent training programmes: Teaching parents positive ways to manage behaviour
• Family therapy: Improving family relationships and communication
• Therapy for the young person: Learning to manage anger and make better decisions
• School support: Extra help with education and behaviour at school

Will it get better?

With the right support, many young people improve. Early intervention is key. Some young people grow out of it, especially if the behaviour started in adolescence rather than childhood.

High-Yield Exam Topics

Sample Viva Questions

Q1: How do you differentiate Oppositional Defiant Disorder from Conduct Disorder?

Model Answer: ODD is characterised by angry/irritable mood, argumentative/defiant behaviour, and vindictiveness. The behaviours are oppositional but do not involve aggression towards people or animals, destruction of property, or serious rule violations. CD is more severe and includes these features: physical aggression, cruelty to people or animals, destruction of property, deceitfulness/theft, and serious rule violations (truancy, running away). ODD is often considered a precursor to CD, though not all children with ODD progress to CD.

Q2: What are callous-unemotional traits and why are they important?

Model Answer: Callous-unemotional (CU) traits are a specifier in DSM-5 for conduct disorder. They include: lack of remorse or guilt, callousness/lack of empathy, unconcern about performance (school, work), and shallow or deficient affect. CU traits are important because they identify a subgroup with worse prognosis. These children have reduced response to standard treatments, are less sensitive to punishment, show reduced amygdala reactivity to fear cues, and are at higher risk of persistent antisocial behaviour into adulthood. They may require more intensive interventions.

Q3: What is the first-line management for a 7-year-old with conduct disorder?

Model Answer: According to NICE CG158, the first-line management for a child under 12 with conduct disorder is a group-based parent training programme. Evidence-based programmes include the Incredible Years (Webster-Stratton), Triple P, and PCIT. These programmes teach parents positive parenting strategies, consistent limit-setting, reducing coercive interactions, and strengthening the parent-child relationship. If parent training is insufficient, child-focused CBT (problem-solving, anger management) can be added. Medication is not first-line but may be considered for comorbidities such as ADHD.

Common Exam Errors

Last Reviewed: 2025-12-24 | MedVellum Editorial Team

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