|In some ways, conduct disorder is just a worse version of ODD. However
recent research suggests that there are some differences. Children with ODD
seem to have worse social skills than those with CD. Children with ODD seem
to do better in school. Conduct disorder is the most serious childhood
psychiatric disorder. Approximately 6-10% of boys and 2-9% of girls have
Here is the Definition:
A. A repetitive and persistent pattern of behavior in which the basic rights
of others or major society rules are violated. At least three of the following criteria must be present
in the last 12 months, and at least one criterion must have been present in the last 6 months.
Aggression to people and animals-
Destruction of property-
Deceitfulness or theft-
Serious violations of rules-
B. The above problem causes significant impairment in social , academic, and occupational functioning.
So how are ODD and CD related?
Currently, the research shows that in many
respects, CD is a more severe form of ODD.
Severe ODD can lead to CD. Milder ODD usually
does not. The common thread that separates
CD and ODD is safety. If a child has CD there
are safety concerns. Sometimes it is the
personal safety of others in the school, family,
or community. Sometimes it is the safety of
the possessions of other people in the school,
family or community. Often the safety of the
child with CD is a great concern.
Children with ODD are an annoyance, but not
especially dangerous. If you have a child with
CD disorder in your home, most likely you do
not feel entirely safe. Or, you do not feel that your things are entirely safe. It is the hardest pediatric
neuropsychiatric disorder to live with as a sibling, parent, or foster parent. Nothing else even comes
close. It is worse than any medical disorder in pediatrics. Some parents have told me that at times it
is worse than having your child die.
Conduct Disorder and comorbidity
It has been common in the past for people to think that conduct disorder is just the beginning of
being a criminal. Up until the last few years, children with conduct disorder were often "written off".
It is now clear that this is true only with a minority of cases. It is very easy to focus on the
management of the CD child and forget to check the child out for other neuropsychiatric disorders.
A careful examination of children with CD almost always reveals other neuro-psychiatric disorders.
Some of the most exciting developments in this area of medicine involve understanding these
phenomena. It is called comorbidty, that is the tendency for disorders to occur together.
It is very common to see children with CD plus another one or two neuro-psychiatric diagnoses. By
far the most common combination is CD plus ADHD. Between 30-50% of children with CD will also
have ADHD. Another common combination is CD plus depression or anxiety. One quarter to one half
of children with CD have either an anxiety disorder or depression. CD disorder plus substance abuse
is also very common. Also common are associations with Learning Disorders, bipolar disorder and
Tourettes Syndrome. It is exceptionally rare for a child to present for evaluation by a pediatric
psychiatrist to have pure CD. Here are some examples of the comorbid presentations:
Looking for comorbid disorders in every child with conduct disorder is absolutely essential. Many of
the treatments of these children depend on what comorbid disorder is also present.
CD plus substance abuse
Sadly, this is very common. In my clinic, every child with CD is assumed to be abusing substances
until proven otherwise. Compared with children who do not have CD, children who have CD are three
times more likely to smoke cigarettes, 2.5 times more likely to drink, and five times more likely to
smoke pot. As far as having a problem from drug use, children with CD a 5.5 times more likely to be
addicted to cigarettes, six times more likely to be alcoholics, 7 times more likely to be addicted to
pot. (16)This is certainly the most common comorbidity and often goes along with the one's below.
When Terry was 9, he told his mom that he wanted to buy lunch instead of bring it. His mom at that
point still believed that some of what Terry said was innocent of any other purpose, and so she let
him. She did notice that he was very hungry when he came home from school. He said the lunches
were small and for an extra 75 cents he could get seconds. She believed this. Two weeks later the
principal called to report that Terry was caught with cigarettes on the playground. Terry's mom was
amazed, as she did not smoke and neither did her husband. Not only that, but he had a whole pack.
Well, it took a lot of "interrogation" to get the story out. The lunch money went to buy cigarettes
from a boy in Jr. High. Terry then smoked a few of those and then sold the rest at a big profit.
His parents remembered that two years later when he was found drunk in the locker room at Jr.
High. Now his parents are lots wiser. Terry still thinks his parents are totally unreasonable. The rule
is you get your allowance and phone privileges as long as those random urine drug screens are
normal. If he does not cooperate, then they are assumed to be positive. So he ended up poor and
lonely for a few weeks, but now that is under control. As far as cigarettes go, if he can buy them, he
can smoke them outside. If he is caught drinking or around people who are drinking, good-bye
allowance and phone. Terry hates it and can't wait until he moves out so he can finally do what he
ADHD plus CD
When these two disorders are present, usually the ADHD symptoms are much more severe than
when ADHD is present without CD.
Stephen is now 14. When his mother thinks back to his infancy, she could actually see it coming at
age 18 months. At that age he got up in the middle of the night, put a chair up to the door, opened
it and went walking outside. The Mounties found him a while later and brought him home. If only that
had been his only contact with them!
Stephen's mother hated school almost as much as Stephen did. Almost every day there were calls
from the school about Stephen. In grade primary he tried to stab a child with scissors. He was
swearing at his teachers by grade one. On Grade two it was stealing lunch money. Every time they
seemed to get one problem under control, he was into something else. Everyone seemed at a loss
about what to do except her brother, who took him Irish mossing every chance he could.
It didn't matter what the weather was like, Stephen was out there. His uncle said that by the time
he was ten, he could do the work of a grown man. There was no fear in Stephen. Cold weather, big
swells, nothing bothered him. He refused to do any homework from fourth grade on. Up until that
grade, his teachers let him go out for a walk around the building every hour or so, but when a set
of keys went missing and were "discovered" by Stephen a few days later, the walks ended. Still,
compared to the last few years, this was easy.
Stephen was suspended from 7th grade after two weeks when he threw a match into a boy's locker.
Why? The boy called him stupid. He was out for a week, then after only two more days, he was
thrown out for making death threats against the teacher. His parents tried home school and they
thought they were getting somewhere. Until they got a call from the bank. They were overdrawn.
When it all came out Stephen had stolen the cash card and figured out the password and had taken
out $500 dollars. They still don't know how he did it. Before they could even sort that out, Stephen
was arrested for vandalizing the school.
He would have only received probation, but after giving the judge the finger, he was sent to the
Shelbourne Youth Centre. It was the staff there that finally figured it out. This guy could not sit still
for anything, he said the first thing that came to his mouth, and was constantly getting in bigger
trouble for it. He saw the doctor, ADHD was diagnosed, and he was given medication for this in the
Youth Centre. But what will happen in two months when he gets out? His motherShe spends a lot of
sleepless nights thinking about that.
CD and depression
Charlene is 14, too. Her life didn't start out quite so difficult. In fact, her mom swears that until
she was almost 10, there were no problems. That is hard for everyone to believe now. Her mom
remembers thinking that Charlene was certainly starting the teen years early. At age 11 she was
having a tantrum about not being able to go out with her boyfriend who was 15. You could hardly
blame her. By the time Charlene was 11, she looked like she was 15 or 16. Unfortunately, she did
not have the maturity of a 16 year old.
She ran away from home at age 12 for a week before they could find her. She brought a bottle of
rum to school and got drunk. But more than this, she was absolutely unbearable to live with. She
had become super defiant, and would fight her parents or anyone else for no reason at all. She
never seemed happy, just angry. Unless she was with her friends, which by age 13 or 14 were 18 or
so. Her parents kept asking themselves, "what had happened to their old daughter?” She was failing
in school mostly because she was never there.
She was never where she told her parents she said she was.
The first clue came when she came home high on something and told her parents she was going up
stairs to bed. They heard a crash and came in the bathroom to find her trying to cut herself with a
broken mirror. Charlene wanted to die. Her boyfriend of two months had left her. For a few weeks
she just hung around the house and lay on her bed and listened to music. Her parents let her out
one night to go to her girlfriend's house. They got a call later that night that Charlene had admitted
to taking a half a bottle of Tylenol.
It is not uncommon that a mood disorder along with CD gets missed. There are usually so many
pressing problems to sort out and so many different stressors, that it isn't until suicide is tried or
talked of that many families, physicians, and other health professionals consider comorbid
depression. Recent studies of teenagers who have committed suicide have found that these children
are about three times more likely to have CD and 15 times
more likely to abuse substances.(15) Suicide is worth worrying about in CD.
CD plus Tourettes, OCD, and ADHD
Marc is now 12. He has seen more doctors, nurses, and psychologists than most people will see in a
lifetime. His father worried that maybe his son could have Tourette's like him, but he never dreamed
it could get like this. When he was 4 he was thrown out of pre-school for fighting. Because of his
reputation, he was the first child where the school approached the parents about getting a teacher's
aide in grade primary rather than the parents approaching the school. Lucky for Marc, he never
seemed to have all of these problems at once. Usually he would have a tic, especially blinking, which
would last a few weeks or so. Then he would have to touch things, and then that might go away,
The tics and OCD were nothing compared to his behavior. His temper was incredible. The usual
pattern was that the excitement of being around other kids would get him so wound up that he was
literally bouncing around. This usually led to pushing, fighting, and punishment. He resisted this and
usually ended up being sent home as they could not deal with him. He attacked him sister. He
attacked his mother and broke her arm. That led to living with different relatives and now a foster
home. No one seemed to be able to manage him.
The new foster parents were actually being bothered the most by his poor sleep and a nearly
constant vocal grunting tic. They brought him to yet another doctor to see if they could do anything
about this. He was placed on some medicine for the tic and amazingly, he behavior improved quite a
bit. For the first time his parents are hopeful that maybe he can come home again.
Diagnosing Conduct Disorder
Conduct disorder is diagnosed like all things in pediatric psychiatry. The child and the caregivers
will be interviewed together and separately to go over the history and check out all other possible
comorbid conditions. Usually there are school reports, too. The child is examined to look for signs
of many disorders. This usually includes some school work, some parts of the physical exam, and
getting the child's perspective on things. Occasionally, there are lab tests and x-rays to do. There
is no lab test that shows these problems.
Prognosis and Course of Conduct Disorder
Perhaps about 30% of conduct disorder children continue with similar problems in adulthood.
It is more common for males with CD to continue on into adult-hood with these types of problems
than females. Females with CD more often end up having mood and anxiety disorders as adults.
Substance abuse is very high. About 50-70% of ten year olds with conduct disorder will be abusing
substances four years later.
Cigarette smoking is also very high. A recent study of girls with conduct disorder showed that they
have much worse physical health. Girls with conduct disorder were almost 6 times more likely to
abuse drugs or alcohol, eight times more likely to smoke cigarettes daily, where almost twice as likely
to have sexually transmitted diseases, had twice the number of sexual partners, and were three
times as likely to become pregnant when compared to girls without conduct disorder (6).
Looked at from the other direction, by the time they are adults, 70% of children no longer show
signs of Conduct disorder. Are they well? Some are, but what often happens is that the comorbid
problems remain or get worse. That is, a girl with CD and depression may end up as an adult with
depression, but no conduct disorder. The same pattern can be true of CD plus bipolar disorder and
other disorders. Here are some examples that illustrate this:
Trisha- ADHD plus CD as a child which eventually disappears
Age 4-12 Classic problems with aggressiveness towards others, hyperactivity, and impulsiveness
along with running away and shoplifting
Age 12-16 ADHD symptoms become less prominent. Continued fights with teachers, shoplifting, and
Age 16-24 Fighting decreases, returns to school and succeeds
Age 25-35 No sign of psychiatric problems
Reggie- ADHD plus Conduct Disorder leads to similar problems as an adult (the minority of cases)
Age 3-7 Reggie shows lots of aggression and hyperactivity
Ages 7-12 Besides being hyperactive, Reggie lies, cheats, steals, and eventually forces a child to take
of their clothes
Ages 13-18 In and out of trouble with the law, and more involved with alcohol, Reggie quits school
at age 16
Age 18-24 Reggie has spent two years of the last six behind bars. He successfully stays off drugs
and alcohol, but meets old friends, quits his job, and is back bootlegging again.
Sarah- CD with more and more signs of mood disorder. Eventually CD disappears.
Age 4-12 Sarah slowly gets into more and more trouble with everyone. She starts to get irritable.
Age 12-18 Sarah continues to have troubles with gambling, shoplifting, and vandalism. Occasional
thoughts of suicide.
Age 18-24 Sarah is hospitalized twice for depression, eventually recovers and seems to settle down
Age 24-50 A few more hospitalizations for post partum depression but no CD features
Mitchell- Learning problems, CD, and drug abuse leads to schizophrenia
Age 4-12 Trouble in School, zero social skills, and constant conflict with family and peers
Age 13-18 Using drugs and occasionally hears voices and sees things. Goes away when he is clean.
Age 18-30 Slowly but surely he gets the substance abuse under control. The hallucinations and
unusual thoughts continue on and require medical treatment.
Jeff- CD plus ADHD leads to mania
Age 4-11 typical ADHD
Age 12-14 Totally out of control. Assaults everyone, gets drunk, pulls fire alarms, attacks father,
steals a car all in the space of a week. Diagnosed by a psychiatrist who visits the youth prison as
Age 14-20 At least 10 episodes of mania and or depression. Hyperactivity and CD not present
except while manic.
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