Conduct Disorder

Quick Reference

Critical Alerts

• Conduct Disorder (CD) is the most common reason for CAMHS referral and a major predictor of adult antisocial personality disorder (ASPD)
• Childhood-onset CD (less than 10 years) has worse prognosis than adolescent-onset; ~40% progress to ASPD
• Callous-Unemotional (CU) traits specifier in DSM-5 identifies subgroup with reduced treatment response and higher risk of persistent antisocial behaviour
• ODD is NOT just "naughty behaviour": It is a clinical disorder with significant functional impairment lasting > 6 months
• ASPD cannot be diagnosed before age 18: Use CD for adolescents; ASPD requires evidence of CD before age 15
• Cruelty to animals and fire-setting are serious warning signs requiring urgent risk assessment
• First-line treatment is parent training programmes: Not medication; NICE CG158 recommends group parent training for children less than 12
• No medication is licensed for CD: Pharmacotherapy is adjunctive for comorbidities (ADHD, depression, severe aggression)
• Multisystemic Therapy (MST) is evidence-based for severe CD in adolescents; addresses family, peer, school, and community factors

Key Diagnostic Criteria Summary (DSM-5)

Emergency Presentations

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Definition

Overview

Conduct Disorder (CD) is a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated. [1,2] It is classified as a disruptive, impulse-control, and conduct disorder in DSM-5, and as a disorder of conduct-dissocial under ICD-11. The condition represents a severe end of the externalising behaviour spectrum, with Oppositional Defiant Disorder (ODD) often considered a precursor or milder form. [3]

The disorder is characterized by four main behavioural domains: (1) aggression towards people and animals, (2) destruction of property, (3) deceitfulness or theft, and (4) serious violations of rules. [1] To meet diagnostic criteria, at least 3 of 15 specified behaviours must be present within the past 12 months, with at least one present in the past 6 months.

CD has profound implications for the individual, family, and society. It is the strongest childhood predictor of adult Antisocial Personality Disorder (ASPD), with approximately 40% of children with childhood-onset CD meeting criteria for ASPD by adulthood. [4] The annual societal cost of a child with CD in the UK exceeds 10 times that of a child without behavioural problems, due to educational, healthcare, social services, and criminal justice involvement. [5]

The DSM-5 introduced the "with limited prosocial emotions" specifier to identify children with callous-unemotional (CU) traits—lack of remorse, shallow affect, and reduced empathy—who represent a more severe phenotype with distinct neurobiological underpinnings and poorer prognosis. [6]

Relationship to Oppositional Defiant Disorder (ODD)

Key Point: ODD involves hostility and defiance but does not include the severe antisocial behaviours (aggression, theft, destruction) that define CD. Many children with CD also meet criteria for ODD, but CD is the more severe diagnosis. [7]

DSM-5 Subtypes and Specifiers

By Age of Onset [1]:

Severity [1]:

With Limited Prosocial Emotions (CU Traits) Specifier [6]: Must persistently display ≥2 of the following over ≥12 months, across multiple relationships and settings:

1. Lack of remorse or guilt: Does not feel bad about wrongdoing (exclude expression only when caught)
2. Callous—lack of empathy: Disregards and unconcerned about feelings of others
3. Unconcerned about performance: Does not care about poor/problematic performance at school, work, or other activities
4. Shallow or deficient affect: Does not express feelings or emotions to others, except in manipulative ways

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Epidemiology

Prevalence and Incidence

Demographic Patterns

Sex Differences:

• Boys: Higher prevalence; more overt aggression (fighting, destruction); earlier onset
• Girls: More covert antisocial behaviour (lying, manipulation, relational aggression); often underdiagnosed; more comorbid internalising disorders [10]

Age:

• ODD symptoms typically emerge age 4-8 years
• CD symptoms typically emerge age 9-14 years
• Adolescent-onset CD peaks 14-16 years

Socioeconomic Factors:

• Prevalence 2-3 fold higher in areas of socioeconomic deprivation
• Strong association with poverty, unemployment, single-parent households, overcrowded housing

Longitudinal Outcomes

Moffitt's Developmental Taxonomy [11]:

• Life-course persistent (LCP) antisocial behaviour: Begins in childhood, continues into adulthood; associated with neuropsychological deficits, difficult temperament, adverse environment
• Adolescence-limited (AL) antisocial behaviour: Begins in adolescence, typically desists by early adulthood; often peer-influenced, "maturity gap"

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Risk Factors and Aetiology

Biopsychosocial Model

CD results from complex interactions between genetic vulnerability, neurobiological factors, family environment, and broader social context. [12]

Genetic Factors

MAOA Gene-Environment Interaction [13]:

• Children with low-activity MAOA genotype who experienced maltreatment had significantly higher rates of antisocial behaviour
• Children with high-activity MAOA genotype were relatively protected despite maltreatment
• Illustrates importance of G×E interactions; genes are not deterministic

Neurobiological Factors

Neurobiological Differences in CU Traits [14]:

• Children with CU traits show:
  • Reduced amygdala activation to fearful faces
  • Reduced autonomic arousal (skin conductance) to distressing stimuli
  • Impaired fear conditioning
• This neurobiological profile is similar to adult psychopathy

Environmental Risk Factors

Patterson's Coercive Family Process Model [15]

Step-by-Step Development of Antisocial Behaviour:

1. Parent makes request (e.g., "Turn off the TV and do homework")
2. Child responds with aversive behaviour (whining, arguing, tantrum)
3. Parent withdraws request to stop aversive behaviour (negative reinforcement for child)
4. Child learns that aversive behaviour "works" → behaviour is reinforced
5. Escalation over time: Both parent and child escalate intensity
6. Generalisation: Child uses coercive strategies outside home (school, peers)
7. Positive behaviours ignored: Parents attend to negative behaviour; positive behaviour not reinforced

Clinical Implication: Parent training interrupts this cycle by:

• Teaching parents to give clear, consistent commands
• Using positive reinforcement for compliance
• Implementing consistent, non-physical consequences for non-compliance

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Clinical Presentation

DSM-5 Diagnostic Criteria for Conduct Disorder [1]

Criterion A: A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least 3 of the following 15 criteria in the past 12 months, with at least 1 criterion present in the past 6 months:

Aggression to People and Animals:

1. Often bullies, threatens, or intimidates others
2. Often initiates physical fights
3. Has used a weapon that can cause serious physical harm to others (bat, brick, broken bottle, knife, gun)
4. Has been physically cruel to people
5. Has been physically cruel to animals
6. Has stolen while confronting a victim (mugging, purse snatching, extortion, armed robbery)
7. Has forced someone into sexual activity

Destruction of Property: 8. Has deliberately engaged in fire-setting with the intention of causing serious damage 9. Has deliberately destroyed others' property (other than by fire-setting)

Deceitfulness or Theft: 10. Has broken into someone else's house, building, or car 11. Often lies to obtain goods or favours or to avoid obligations (i.e., "cons" others) 12. Has stolen items of nontrivial value without confronting a victim (shoplifting, forgery)

Serious Violations of Rules: 13. Often stays out at night despite parental prohibitions, beginning before age 13 years 14. Has run away from home overnight at least twice while living in parental or surrogate home, or once without returning for a lengthy period 15. Is often truant from school, beginning before age 13 years

Criterion B: The disturbance in behaviour causes clinically significant impairment in social, academic, or occupational functioning.

Criterion C: If the individual is age 18 years or older, criteria for Antisocial Personality Disorder are not met.

Symptom Presentation by Context

Red Flags Requiring Urgent Assessment

[!CAUTION] Red Flags — Urgent Assessment and Risk Management Required:

• Cruelty to animals (strong predictor of violence; part of historical "MacDonald triad")
• Fire-setting with intent to cause harm (serious risk to others)
• Use of weapons (escalating violence)
• Sexual aggression or coercion (significant safeguarding concern)
• Expressed intent to harm specific individuals (threat assessment needed)
• Suicidal ideation or self-harm (comorbid depression, requires full psychiatric assessment)
• Significant substance misuse (especially stimulants, alcohol)
• Psychotic symptoms (rare but important to exclude)

Comparison: ODD vs CD vs ASPD

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Assessment

Comprehensive Assessment Domains

Mental State Examination (MSE)

Structured Assessment Tools

Physical Investigations

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Comorbidities

Prevalence of Comorbid Conditions

ADHD-CD Comorbidity [16]

• Shared genetic risk: Common genetic vulnerability for hyperactivity/impulsivity and conduct problems
• Clinical implications:
  • ADHD symptoms often precede and predict CD
  • ADHD treatment (stimulants) may reduce conduct problems
  • Comorbid ADHD + CD has worse prognosis than either alone
  • Always assess for ADHD in children presenting with conduct problems

Depression in CD

• Often underdiagnosed due to externalising presentation masking internalising symptoms
• Associated with higher suicide risk
• Girls with CD have particularly high rates of comorbid depression
• Treatment of depression may improve engagement with CD interventions

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Management

Management Principles

1. Multimodal approach: No single intervention is sufficient; address child, family, school, and community
2. Evidence-based interventions: NICE CG158 recommends specific parent training programmes and MST
3. Early intervention: Earlier treatment has better outcomes
4. Address comorbidities: Treat ADHD, depression, learning difficulties
5. Multiagency working: Coordinate with education, social services, youth justice
6. Risk management: Ongoing assessment of risk to self and others
7. Long-term perspective: CD requires sustained intervention, not one-off treatment

NICE CG158 Recommendations [17]

Key NICE Recommendations:

1. First-line for children aged 3-11: Group parent training programmes
2. First-line for adolescents 11-17: Group parent training (if still living with parent) OR multimodal interventions including MST
3. Child-focused interventions (problem-solving, anger management) as adjunct or if parent training not suitable
4. School-based interventions for prevention
5. No routine use of medication for CD; consider for comorbidities

Management Algorithm

                    CONDUCT DISORDER MANAGEMENT
                              ↓
┌─────────────────────────────────────────────────────────────────────┐
│                     COMPREHENSIVE ASSESSMENT                         │
├─────────────────────────────────────────────────────────────────────┤
│  ➤ Confirm diagnosis (DSM-5/ICD-11 criteria)                        │
│  ➤ Determine onset type (childhood vs adolescent)                   │
│  ➤ Assess for CU traits specifier                                   │
│  ➤ Screen for comorbidities (ADHD, depression, SUD, LD)            │
│  ➤ Risk assessment (harm to self/others)                            │
│  ➤ Family assessment (parenting, family conflict, psychopathology) │
│  ➤ School assessment (attainment, exclusions, peer relationships)  │
│  ➤ Identify protective factors and motivation for change           │
└─────────────────────────────────────────────────────────────────────┘
                              ↓
┌─────────────────────────────────────────────────────────────────────┐
│           FIRST-LINE: PARENT TRAINING (AGE less than 12 YEARS)               │
├─────────────────────────────────────────────────────────────────────┤
│  ➤ Group parent training programmes (NICE recommended):            │
│    • The Incredible Years (Webster-Stratton)                        │
│    • Triple P (Positive Parenting Programme)                        │
│    • Parent-Child Interaction Therapy (PCIT) - ages 2-7             │
│                                                                      │
│  ➤ Key components:                                                   │
│    • Play and relationship building                                  │
│    • Praise and positive reinforcement                               │
│    • Clear, consistent commands and limit-setting                   │
│    • Non-violent discipline strategies (time-out, consequences)     │
│    • Reducing coercive parent-child interactions                    │
│                                                                      │
│  ➤ Duration: Typically 10-14 weekly sessions                        │
│  ➤ NNT for clinically significant improvement: 3-5                  │
└─────────────────────────────────────────────────────────────────────┘
                              ↓
┌─────────────────────────────────────────────────────────────────────┐
│         SECOND-LINE / ADOLESCENTS: MULTIMODAL INTERVENTIONS         │
├─────────────────────────────────────────────────────────────────────┤
│  ➤ Multisystemic Therapy (MST) - for adolescents 11-17 with severe │
│    conduct problems:                                                 │
│    • Intensive, community-based                                      │
│    • Addresses family, peer, school, community factors              │
│    • Therapist available 24/7                                        │
│    • 3-5 months duration, 3-5 times weekly contact                  │
│    • Evidence: Reduced recidivism, out-of-home placements           │
│                                                                      │
│  ➤ Functional Family Therapy (FFT)                                   │
│    • 8-30 sessions over 3-6 months                                   │
│    • Addresses family communication and problem-solving             │
│                                                                      │
│  ➤ Multidimensional Treatment Foster Care (MTFC)                    │
│    • For youth who cannot remain at home                             │
│    • Specially trained foster families                               │
│    • Community-based alternative to residential care                │
└─────────────────────────────────────────────────────────────────────┘
                              ↓
┌─────────────────────────────────────────────────────────────────────┐
│              CHILD/ADOLESCENT-FOCUSED INTERVENTIONS                  │
├─────────────────────────────────────────────────────────────────────┤
│  ➤ Cognitive-Behavioural Therapy (CBT):                             │
│    • Problem-solving skills training                                 │
│    • Anger management                                                │
│    • Social skills training                                          │
│    • Perspective-taking and empathy development                     │
│                                                                      │
│  ➤ Indicated when:                                                   │
│    • Parent training alone insufficient                              │
│    • Adolescent with limited parental involvement                   │
│    • Specific deficits in problem-solving or social skills          │
└─────────────────────────────────────────────────────────────────────┘
                              ↓
┌─────────────────────────────────────────────────────────────────────┐
│            PHARMACOTHERAPY (ADJUNCTIVE, NOT FIRST-LINE)             │
├─────────────────────────────────────────────────────────────────────┤
│  ➤ No medication licensed specifically for CD                       │
│                                                                      │
│  ➤ Treat comorbidities:                                              │
│    • ADHD: Methylphenidate, lisdexamfetamine, atomoxetine           │
│      - May reduce impulsivity and associated conduct problems       │
│    • Depression: SSRIs (fluoxetine first-line in children)          │
│      - Cautious use; monitor for activation                         │
│                                                                      │
│  ➤ Severe, refractory aggression (after psychosocial interventions │
│    failed):                                                          │
│    • Risperidone (off-label): 0.25-2 mg/day                         │
│      - Short-term use only; monitor metabolic effects               │
│      - Evidence: RCTs show reduction in aggression [18]             │
│    • Aripiprazole: Alternative second-generation antipsychotic      │
│                                                                      │
│  ⚠️ Antipsychotics: Use with caution, short-term, regular review    │
│     Monitor: Weight, glucose, lipids, prolactin, QTc                │
└─────────────────────────────────────────────────────────────────────┘
                              ↓
┌─────────────────────────────────────────────────────────────────────┐
│                    MULTIAGENCY INVOLVEMENT                           │
├─────────────────────────────────────────────────────────────────────┤
│  ➤ School liaison: EHCP, learning support, behavioural strategies  │
│  ➤ Social services: Safeguarding, family support                    │
│  ➤ Youth Offending Team (YOT): If criminal justice involvement     │
│  ➤ Substance misuse services: If SUD present                        │
│  ➤ Educational psychology: Learning assessment                      │
│  ➤ CAMHS: Ongoing mental health support                              │
└─────────────────────────────────────────────────────────────────────┘

Evidence-Based Parent Training Programmes

Multisystemic Therapy (MST) [20]

Key Principles:

1. Finding the fit: Understand how problems "make sense" in the youth's ecology
2. Positive and strength-focused: Emphasise systemic strengths
3. Increasing responsibility: Empower family to address problems
4. Present-focused, action-oriented, well-defined interventions
5. Targeting sequences of behaviour: Address patterns maintaining problems
6. Developmentally appropriate: Match interventions to developmental stage
7. Continuous effort: Require daily or weekly effort by family
8. Evaluation and accountability: Continuously monitor outcomes
9. Generalisation: Promote lasting change across settings

MST Evidence:

• Meta-analyses show reduced recidivism, out-of-home placements, and improved family functioning
• More effective than residential treatment, incarceration, individual therapy
• Cost-effective despite intensive nature
• Effects sustained at follow-up

Treating Callous-Unemotional Traits

• Standard parent training may be less effective for children with high CU traits
• Adaptations for CU traits:
  • Greater emphasis on positive reinforcement (reward-based strategies)
  • Less reliance on punishment-based strategies
  • Focus on recognising and responding to emotional cues
  • "Emotion-recognition training" and perspective-taking
  • Parental warmth and positive involvement
• Evidence emerging for modified interventions [14]

Pharmacotherapy Evidence

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Prognosis

Prognostic Factors

Long-Term Outcomes

Childhood-Onset CD:

• ~40% develop ASPD by adulthood
• ~25% have persistent criminal involvement
• Elevated rates of: substance use disorders, unemployment, relationship difficulties, premature mortality

Adolescent-Onset CD:

• ~10-20% develop ASPD
• Many "desist" (stop antisocial behaviour) in early adulthood
• Prognosis generally better but not without risk

CU Traits:

• Associated with more severe violence, more persistent antisocial behaviour, poorer treatment response
• May represent developmental pathway to psychopathy
• Early intervention particularly important

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Prevention

Universal Prevention

• Whole-school positive behaviour programmes
• Social-emotional learning curricula
• Anti-bullying interventions

Selective Prevention (High-Risk Groups)

• Triple P Level 1-2 for high-risk communities
• Home visiting programmes (e.g., Nurse-Family Partnership)
• Early childhood programmes (e.g., Sure Start, Head Start)

Indicated Prevention (Early Symptoms)

• Parent training for children with early conduct problems
• School-based social skills programmes
• Early identification and intervention for ADHD

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Special Considerations

Safeguarding

• Many children with CD have experienced abuse or neglect
• CD may be a manifestation of trauma
• Assess for ongoing safeguarding concerns
• Report concerns to appropriate agencies

Forensic Issues

• Age of criminal responsibility in England/Wales: 10 years
• Youth courts deal with offenders under 18
• Youth Offending Teams provide supervision and intervention
• Confidentiality considerations when involved with justice system

Female Presentations

• CD may be underdiagnosed in girls
• More relational aggression, less physical aggression
• Higher rates of comorbid depression, self-harm
• Greater risk of early pregnancy, abusive relationships

Transition to Adult Services

• Plan transition from CAMHS to adult mental health services at age 17-18
• If ASPD criteria met at 18, diagnosis changes
• Ensure continuity of care and handover

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Patient and Carer Education

For Parents/Carers

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 serious behaviour that causes real problems at home, school, or in the community. It's not your fault as a parent, and it can be treated."

What causes it? "There's no single cause. It usually results from a combination of a child's temperament, brain development, family environment, and life experiences. Many children with conduct disorder have also experienced difficult circumstances like abuse, neglect, or family conflict."

How is it treated? "The most effective treatment is parent training programmes. These teach positive parenting strategies that reduce conflict and improve your relationship with your child. For teenagers, family therapy or intensive community programmes may be recommended. Medication is not usually the main treatment but may help if your child also has ADHD or depression."

What can I do to help?

• Attend and engage with parent training
• Be consistent with rules and consequences
• Use praise and positive attention for good behaviour
• Avoid harsh punishment
• Work with school and other agencies
• Look after your own wellbeing

For Young People

What is conduct disorder? "Conduct disorder means you've been having serious problems with your behaviour - like getting into fights, breaking rules, or getting into trouble with the law. It's not about labelling you as a 'bad person'. Understanding why this is happening can help you and your family find ways to make things better."

What help is available? "There are programmes that help you and your family communicate better and solve problems without conflict. You might also work on managing anger and thinking through consequences. If you're struggling with things like ADHD or depression, treatment for those can help too."

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Examination Focus

High-Yield Exam Topics

Sample Viva Questions and Model Answers

Q1: A 6-year-old boy is referred with aggression, fire-setting, and cruelty to the family cat. His mother describes difficult behaviour since age 3. What is your approach?

Model Answer: "This presentation is concerning for childhood-onset conduct disorder with serious warning signs. My approach would be:

Assessment:

• Comprehensive psychiatric assessment including detailed behavioural history, developmental history, family assessment, and school report
• Specifically assess for DSM-5 conduct disorder criteria - this child shows aggression to animals (cruelty to cat), destruction of property (fire-setting), and likely other criteria
• Assess for callous-unemotional traits using the ICU questionnaire
• Screen for comorbidities, especially ADHD and language difficulties
• Conduct thorough risk assessment - fire-setting and animal cruelty are serious risk markers
• Assess safeguarding concerns and trauma history

Key Considerations:

• Childhood-onset (less than 10 years) indicates worse prognosis
• Fire-setting and animal cruelty are serious warning signs requiring urgent intervention
• Must assess for CU traits specifier

Management:

• First-line: Evidence-based parent training programme (e.g., Triple P or Incredible Years)
• For age 6, PCIT would be particularly appropriate with its live coaching approach
• Liaise with school for behavioural strategies
• If comorbid ADHD identified, consider stimulant medication
• Multiagency involvement including social services if safeguarding concerns
• Long-term follow-up required given poor prognostic indicators"

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

Model Answer: "Callous-unemotional traits are a DSM-5 specifier for conduct disorder called 'with limited prosocial emotions'. They are defined by the persistent presence (≥12 months) of at least 2 of 4 features:

1. Lack of remorse or guilt - does not feel bad about wrongdoing
2. Callous-lack of empathy - disregards feelings of others
3. Unconcerned about performance - indifferent to poor school or work performance
4. Shallow or deficient affect - limited emotional expression except when manipulative

Clinical Importance:

Neurobiological: Children with CU traits show reduced amygdala reactivity to fearful faces, blunted autonomic responses, and impaired fear conditioning - similar to adult psychopathy.

Treatment Response: Standard parent training is less effective. These children may respond better to reward-based interventions rather than punishment-based strategies.

Prognosis: CU traits predict more severe and persistent antisocial behaviour, greater violence, and higher risk of developing psychopathy in adulthood.

Assessment: All children with CD should be assessed for CU traits using tools like the Inventory of Callous-Unemotional Traits. This informs prognosis and treatment planning."

Q3: Compare parent training and multisystemic therapy. When would you use each?

Model Answer: "Both are evidence-based interventions for conduct problems, but they differ in intensity, target population, and approach.

Parent Training (e.g., Incredible Years, Triple P):

• Target: Children less than 12 years with mild-moderate conduct problems
• Format: Group-based, 10-14 weekly sessions
• Focus: Modifying parenting behaviour; based on Patterson's coercive family process model
• Content: Positive reinforcement, consistent limit-setting, reducing coercive interactions
• NNT: 3-5 for clinically significant improvement
• NICE recommendation: First-line for children 3-11 years

Multisystemic Therapy (MST):

• Target: Adolescents 11-17 with severe CD, criminal involvement, at risk of out-of-home placement
• Format: Intensive, community-based, 3-5 months, therapist available 24/7
• Focus: Entire ecology - family, peers, school, community
• Content: Family therapy, school liaison, addressing deviant peers, skill-building
• Evidence: Reduced recidivism, reduced out-of-home placements
• NICE recommendation: For adolescents with severe problems

When to use parent training: Young children (less than 12), less severe problems, parents engaged and able to attend sessions.

When to use MST: Adolescents, severe problems, criminal involvement, at risk of care or custody, need intensive intervention addressing multiple systems."

Q4: How would you manage comorbid ADHD in a child with conduct disorder?

Model Answer: "ADHD is comorbid in 50-70% of children with conduct disorder and is a key target for intervention.

Assessment:

• Use standardised rating scales (Conners') with parent and teacher informants
• Confirm ADHD diagnosis separately from CD
• Assess which symptoms are ADHD-related vs CD-related (impulsive aggression vs planned aggression)

Treatment Approach:

• Treat both conditions, but ADHD treatment may improve some conduct problems
• Parent training remains first-line for CD component
• Stimulant medication (methylphenidate) is first-line for ADHD
• Evidence shows stimulants can reduce impulsive aggression and improve behavioural regulation
• If substance misuse concern, consider atomoxetine (non-stimulant)

Integrated Care:

• Combine pharmacotherapy for ADHD with parent training for CD
• School behavioural strategies for both conditions
• Monitor response and adjust treatment

Prognosis:

• Comorbid ADHD + CD has worse prognosis than either alone
• Untreated ADHD may worsen CD trajectory
• Early, comprehensive treatment of both conditions improves outcomes"

Common Exam Errors

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Key Clinical Pearls

Diagnostic Pearls

1. DSM-5 criteria require 3 of 15 behaviours: Not just "aggressive behaviour"

• must span categories

2. ODD and CD are different: ODD is defiant/irritable but no aggression to persons or property destruction; CD is more severe
3. Childhood-onset is worse prognosis: less than 10 years onset predicts persistence to ASPD
4. CU traits specifier is essential: Identifies subgroup with different neurobiology and treatment response
5. ASPD cannot be diagnosed under 18: Use CD for adolescents; ASPD requires CD before age 15
6. 50% have comorbid ADHD: Always screen; treating ADHD may improve conduct

Treatment Pearls

1. Parent training is first-line for less than 12 years: Not individual therapy for the child
2. MST for severe adolescent CD: Intensive, ecological, evidence-based
3. No medication licensed for CD: Pharmacotherapy only for comorbidities or severe refractory aggression
4. Risperidone for aggression is off-label and short-term: Monitor metabolic effects
5. CU traits require adapted intervention: More reward-based, less punishment-based
6. Multiagency working is essential: School, social services, YOT

Red Flag Pearls

1. Animal cruelty and fire-setting are serious: Urgent risk assessment required
2. Depression is often missed: Screen for self-harm and suicidality
3. Substance misuse worsens prognosis: Always assess
4. Family psychopathology matters: Parental ASPD, depression, substance use

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Quality Metrics

Performance Indicators

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Medicolegal Considerations

Age of Criminal Responsibility

• England and Wales: 10 years
• Children aged 10-17 are dealt with in the Youth Court
• Doli incapax (presumption of incapacity) abolished for 10-14 year olds in 1998

Confidentiality

• Usual rules of confidentiality apply
• Disclosure without consent may be necessary for:
  • Safeguarding children
  • Prevention of serious harm to others
  • Public interest (serious crime)
• Involve legal/ethics advice when uncertain

Information Sharing

• Share information with other agencies (school, social services, YOT) in best interests of child
• Consider child's capacity to consent
• Parents/carers usually involved but consider child's rights

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Clinical Vignettes for Teaching

Case 1: Childhood-Onset CD with CU Traits

Presentation: A 9-year-old boy is referred after being permanently excluded from school for seriously injuring a classmate. His mother reports that he shows no remorse, has been cruel to the family pet, and has deliberately started a fire in the garden. Behaviour problems began at age 4.

Discussion Points:

• Childhood-onset (less than 10 years) - worse prognosis
• Multiple criteria: aggression to persons, animal cruelty, fire-setting
• CU traits: lack of remorse, callousness
• Urgent risk assessment needed
• First-line: parent training, but may be modified for CU traits
• Screen for ADHD

Case 2: Adolescent-Onset CD with ADHD

Presentation: A 14-year-old girl is brought by police after being caught shoplifting for the third time. Her mother says she has been staying out late, missing school, and hanging out with "the wrong crowd." She was a well-behaved child until age 12. Her concentration has always been poor.

Discussion Points:

• Adolescent-onset (≥10 years) - better prognosis, often peer-influenced
• Criteria: theft, rule violations, truancy
• Screen for ADHD (poor concentration)
• Screen for depression (girls high risk)
• Management: MST or FFT; treat ADHD if confirmed
• Involve YOT given police involvement

Case 3: ODD vs CD Distinction

Presentation: An 8-year-old boy is referred with defiant behaviour: argues with adults, refuses to follow rules, deliberately annoys others, and is often "touchy" and easily annoyed. He has not been physically aggressive to people or animals, has not destroyed property, and has not stolen.

Discussion Points:

• This is ODD, not CD: no aggression to persons/animals, no destruction, no theft
• ODD may precede CD but does not always progress
• First-line: parent training
• Monitor for progression to CD

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Additional Viva Questions

Q5: What is the evidence for multisystemic therapy?

Model Answer: "MST has the strongest evidence base of any intervention for severe adolescent conduct disorder. Key evidence includes:

• Multiple RCTs: Show reduced recidivism (25-70% reduction), reduced out-of-home placements, improved family functioning
• Comparison trials: MST outperforms individual therapy, residential treatment, and usual services
• Long-term follow-up: Effects sustained at 10+ years in some studies
• Cost-effectiveness: Despite high intensity, MST is cost-effective compared to incarceration or residential care
• Meta-analyses: Curtis et al. (2004) and others confirm moderate effect sizes

MST works by addressing the "ecology" of the young person - family, peers, school, and community. It is intensive (3-5 months, therapist available 24/7) but delivered in the community, keeping the young person in their natural environment."

Q6: How would you approach a young person with CD who denies any problems?

Model Answer: "Denial and poor insight are common in CD. My approach would be:

1. Engage the young person: Build rapport; avoid confrontation; use motivational interviewing techniques
2. Multiple informants: Gather information from parents, teachers, records - don't rely solely on self-report
3. Explore their perspective: Understand how they see the situation; what would they change?
4. Identify goals they care about: Even if they don't see behaviour as problematic, they may want to avoid exclusion, stay out of trouble, etc.
5. Family-focused intervention: Parent training and family therapy do not require the child to accept they have a problem
6. Gradual engagement: Change often occurs over time with consistent intervention
7. Monitor for coercion: Forced treatment is rarely effective; try to find intrinsic motivation
8. Consider CU traits: Shallow affect and lack of remorse may be part of the presentation"

Q7: What safeguarding considerations are relevant in CD?

Model Answer: "Safeguarding is a critical consideration in CD:

Child as victim:

• Many children with CD have experienced abuse, neglect, or witnessed domestic violence
• CD may be a trauma response
• Always assess trauma history sensitively
• Report concerns to social services
• Consider trauma-informed care approaches

Child as perpetrator:

• CD behaviours may constitute offences (assault, theft, arson)
• Age of criminal responsibility in England/Wales is 10
• May need to involve police if serious
• Balance therapeutic vs legal responses
• Information sharing with YOT

Risk to others:

• Assess risk to specific individuals (parents, siblings, peers)
• Fire-setting and weapon use are particular concerns
• Safety planning with family
• Consider admission if risk unmanageable

Duty to protect:

• If a young person discloses intent to harm a specific individual, consider duty to warn
• Document all risk assessments and decisions"

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OSCE Stations

Station 1: Parent Consultation

Scenario: You are an ST4 in child psychiatry. Mrs. Jones has brought her 7-year-old son, Ethan, for assessment following a school referral for aggressive behaviour. Take a history from the mother.

Marks available for:

• Detailed behavioural history (specific incidents, onset, severity, frequency)
• DSM-5 symptom coverage
• Developmental history
• Family history and functioning
• School history
• Comorbidity screening (ADHD, depression)
• Risk assessment
• Communication skills

Station 2: Explaining Diagnosis and Management

Scenario: You have assessed 7-year-old Ethan and diagnosed conduct disorder. Explain the diagnosis and management plan to his mother.

Key points to cover:

• Explain what conduct disorder is (pattern of behaviour, not just "naughty")
• It's not her fault
• First-line is parent training programme
• Explain what parent training involves
• Multiagency involvement (school)
• Prognosis (early treatment improves outcomes)
• Answer questions empathetically

Station 3: Risk Assessment

Scenario: A 13-year-old boy with known conduct disorder has expressed intent to "hurt" a specific classmate who bullied him. Conduct a risk assessment.

Key elements:

• Nature of threat (specific, credible?)
• Means (access to weapons?)
• Past violence history
• Protective factors
• Mental state (intoxication, psychosis?)
• Safeguarding both children
• Management plan (safety, communication with school, parents)

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Last Reviewed: 2026-01-09 | MedVellum Editorial Team

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Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.