Principal Authors: Dr. med. univ. Hans Steiner and John E. Dunne, M.D. This Summary was developed by the Work Group on Quality Issues: John E. Dunne, M.D., Chair; Valerie Arnold, M.D., William Bernet, M.D., Oscar Bukstein, M.D., Joan Kinlan, M.D., and Jon McLellan, M.D. AACAP Staff: L. Elizabeth Sloan, L.P.C. The full text of the Practice Parameters for the Assessment and Treatment of Children and Adolescents with Conduct Disorder is available to Academy members on the World Wide Web (www.aacap.org) and appears in the October 1997 supplement to the JAACAP. The full text of the parameters was reviewed at the 1996 Annual Meeting of the American Academy of Child and Adolescent Psychiatry. The full text and this Summary were approved by Council in March 1997. © 1997 by the American Academy of Child and Adolescent Psychiatry.
ABSTRACT
This summary of the practice parameters describes the diagnosis, treatment, and prevention of conduct disorder in children and adolescents. The rationales for these recommendations are based on a review of the scientific literature and clinical consensus, which are contained in the complete document. Clinical features of youths with conduct disorder include predominance in males, low socioeconomic status, and familial aggregation. Important continuities to oppositional defiant disorder and antisocial personality disorder have been documented. Extensive comorbidity, especially with other externalizing disorders, depression, and substance use, has been documented and has significance for prognosis. Clinically significant subtypes exist according to age of onset, overt or covert conduct problems, and levels of restraint exhibited under stress. To be effective, treatment must be multimodal, address multiple foci, and continue over extensive periods of time. Early treatment and prevention seem to be more effective than later intervention. Key Words: conduct disorder, adolescents, children, disruptive behavior, delinquency, practice parameters.
The recommendations presented in these parameters give clinicians direction in the assessment and treatment of children and adolescents who present with antisocial behaviors, including conduct disorder (CD). Recommendations are based on extensive review of the scientific literature and clinical consensus among experts in the subject. The literature review, including references, and the rationale for specific recommendations are contained in the complete document (American Academy of Child and Adolescent Psychiatry, 1997).
Conduct disorder was chosen as the subject of practice parameters because it is prevalent in the community and in psychiatric settings, and is a severe, complex form of psychopathology, presenting with multiple deficits in a range of domains of functioning. Psychiatric interventions can be successful only if they are carefully coordinated, aimed at multiple domains of dysfunction, and delivered during extensive periods of time.
The prevalence of CD in the general population of children and adolescents is estimated to be between 1.5% and 3.4%. Using arrest rates as the defining criterion, prevalence appears even higher. Approximately 40% of children and adolescents with CD go on to develop Antisocial Personality Disorder (APD), with the prevalence of APD in the general population of adults estimated to be 2.6%.
These parameters present the risk-resilience model of the development of antisocial behaviors and describe various subtypes of CD, particularly the childhood-onset and adolescent-onset, and the under- and over-restrained subtypes, which have therapeutic and prognostic implications.
DIAGNOSTIC ASSESSMENT
The assessment of CD requires collecting data from multiple informants in multiple settings using multiple methods over time, in order to develop realistic targets. Although the order of obtaining data may vary, the evaluator should interview both the patient and the parents, separately and together, to obtain history. It also may be desirable to interview other family members and professionals familiar with the patient. Releases for contact with medical, school, social service, and juvenille justice personnel should be obtained as indicated. History-taking should include the patient's prenatal and birth history, including substance abuse by the mother, maternal infections, and medications. Developmental history should include problems with attachment, temperament, aggression, oppositional behavior, attention, and impulse control. There should be inquiry about the presence of physical and sexual abuse, both as a victim and perpetrator. DSM-IV target symptoms, and the course of their development, should be reviewed. The quality and quantity of peer relationships should be assessed.
Obtain information about school functioning. This could include results of intelligence testing, achievement test data, academic performance, and behavioral reports. This may be obtained in person, by phone, or through written reports from the school principal, psychologist, teacher, and nurse. Standard parent- and teacher-rating scales of the patient's behavior may be useful. Referral for intelligence testing, speech and language assessment, testing for learning disability, and neuro-psychiatric testing may be useful if available test data are not sufficient to evaluate cognitive functioning.
Family assessment is an important part of the evaluation and should include the family's coping style, resources, stressors, socioeconomic status, and social support or isolation. The parents' style of setting limits, managing the child's aggression, and resolving conflict should be assessed. Parental harshness, abuse, neglect, permissiveness, and inconsistency should be noted, as should parents' and patient's coercive interaction cycles leading to reinforcement of non-compliance. Obtain a history of family antisocial behaviors, including incarceration, violence and physical or sexual abuse of the patient or other family members. Screen for family history of ADHD, CD, substance use disorders, specific developmental disorders (i.e., learning disabilities), tic disorders, somatization disorder, mood disorders, and personality disorders. Obtain any history of adoptions and placements in foster care and institutions.
Evidence of a physical evaluation within the last twelve months is necessary. A baseline pulse rate is useful, particularly if medications may be part of the treatment plan. A vision or hearing screening may be indicated. Other medical and neurological conditions, with focus on central nervous system (CNS) pathology (head injury, seizure disorder, or other CNS illness), chronic illnesses, and extensive somatization, should be evaluated. A urine or blood drug screen may be indicated, especially when clinical evidence suggests substance abuse that the patient denies.
The interview with the patient, which may precede the parental interview, should include family history, the patient's personal substance use and sexual history (including sexual abuse of others). DSM-IV target symptoms may not be apparent or acknowledged during the patient interview, but may be detected by interviewing parents and other informants. Evaluate the patient's capacity for attachment, trust, and empathy; tolerance for and discharge of impulses; and capacity to show restraint, accept responsibility for actions, and experience guilt. Assess cognitive functioning; mood, affect, self-esteem, and suicidal potential; presence and quality of peer relationships (loner, popular, drug-, crime-, or gang-oriented friends); and disturbances of ideation (inappropriate reactions to the environment, paranoia, dissociative episodes, and suggestibility). Self-report instruments might provide useful information.
DIAGNOSTIC FORMULATION
Identify the presence of DSM-IV target symptoms from the assessment data. In addition, consider the following: biopsychosocial stressors, especially sexual and physical abuse, separation, divorce, or death of key attachment figures; educational potential, disabilities and achievement; peer, sibling, and family problems and strengths; environmental factors including a disorganized home, lack of supervision, presence of child abuse or neglect, mental illness or substance abuse in the parents, and environmental neurotoxins, such as lead; adolescent or child ego development, especially the ability to form and maintain relationships.
If the child or adolescent meets the diagnostic criteria for CD, attempt to subtype the disorder as childhood- vs. adolescent-onset, overt vs. covert vs. authority-conflicted, under- vs. over-restrained, and socialized vs. under-socialized. If the patient's problem does not meet the criteria for CD, other diagnoses should be considered primary with conduct symptoms complicating their presentation. Consider these disorders which are listed in decreasing likelihood of being confused with or comorbid with CD: attention deficit-hyperactivity disorder, oppositional defiant disorder, intermittent explosive disorder, substance use disorder, mood disorders (bipolar and depressive), post-traumatic stress disorder, dissociative disorders, borderline personality disorder, somatization disorder, adjustment disorders, organic brain disorder, seizure disorder, paraphilias, narcissistic personality disorder, specific developmental disorders (i.e., learning abilities), mental retardation, and schizophrenia. Of the comorbidities ADHD is the most virulent and has been repeatedly found to overlap with CD. Although differentiating among comorbidities is complicated in highly compounded forms of CD, in general, the persistent pattern of violating rules and the rights of others, along with accumulating legal consequences, is unique to CD and will assist the clinician with differential diagnosis.
TREATMENT
Outpatient treatment of CD involves intervention in the family, school, and peer group, as well as with the patient. The predominance of externalizing symptoms in multiple domains of functioning calls for interpersonal and psycho-educational modalities rather than an exclusive emphasis on intrapsychic and psychopharmacological approaches. As a chronic condition, CD requires extensive treatment and long-term follow-up. Some milder forms of CD, commonly seen in private practice, require only minor intervention, such as consultation with parents and schools. Severe CD is likely to involve comorbidities that require treatment. Family interventions include parent guidance, training, and family therapy. Identify and work with parental strengths. Train parents to establish consistent positive and negative consequences and well-defined expectations and rules. Work to eliminate harsh, excessively permissive, and inconsistent behavior management practices. Arrange for treatment of psychopathology, especially substance abuse, in the parents or other family members. Individual and group psychotherapy with the adolescent or child may be useful. The technique chosen (supportive versus explorative, cognitive versus behavioral) should depend upon the patient's age, processing style, and ability to engage in treatment. Usually, a combination of behavioral and explorative approaches is indicated, especially when there are internalizing and externalizing comorbidities. Psychotherapy should be supplemented by psychosocial skill-building techniques.
Other psychosocial interventions should be considered. For example, peer intervention, to help the patient replace a deviant peer group with a socially appropriate one, is usually indicated. School intervention to achieve appropriate placement and promote an alliance between parents and the school, as well as to promote prosocial peer group interactions, is often useful. Working with the juvenile justice system, including judges and probation officers, to introduce or support court supervision and limit-setting, is usually beneficial. Involving social service agencies to help the family gain access to benefits and services, and community support programs, such as Big Brother and Big Sister Programs, Friends Outside, and Planned Parenthood, may be appropriate. Job training and independent living skills training may be useful.
In all cases, pharmacological intervention alone will be insufficient to manage and treat CD. Pharmacotherapy may be part of treatment, however, primarily for comorbid disorders and target symptoms. Medications are recommended only on the basis of clinical experience and demonstrated efficacy in some patients. Adequate controlled studies of efficacy in patients with CD and comorbid disorders are lacking. However, stimulants for ADHD, antidepressants for mood and anxiety disorders, low-dose major tranquilizers for paranoid ideation with aggressiveness, and anti-convulsants for partial complex seizure disorders should be used as indicated. Antidepressants, lithium carbonate, carbamazepine, and propranolol are currently used clinically for CD, but rigorous scientific studies to demonstrate their efficacy have not been done. The risk of neuroleptics may exceed their usefulness in the treatment of aggression in CD and require careful consideration before use.
Out-of-home placement, such as in crisis shelters, group homes, and residential treatment, may be indicated by severe family dysfunction, marked non-compliance, or persistent involvement with a deviant peer group.
There is significant agreement on criteria for hospitalization of patients with CD, but level of care decision-making is complex and unsupported by empirical data. The psychiatric professional should choose the least restrictive intervention that fulfills both short- and long-term needs of the patient. The following criteria from Documentation of Medical Necessity of Child and Adolescent Psychiatric Treatment: Guidelines for Use in Managed Care, Third Party Coverage and Peer Review and Level of Care Placement Criteria for Psychiatric Illness indicate the need for hospitalization. These criteria include the significant risk of death, significant injury, pain or distress, disability or dysfunction resulting from mood, anxiety, behavior, perceptual, or thought disorders. Another criterion is failure of treatment at less intensive levels of care. The DSM-IV criteria for CD often are insufficient to justify hospitalization. Symptoms of substance abuse, self-destructive or suicidal behavior, or homicidal or aggressive behavior necessitate hospital treatment and may warrant the concurrent diagnoses of ADHD, intermittent explosive disorder, affective disorder, bipolar disorder, or substance use disorder.
Inpatient, partial-hospitalization, and residential treatment programs should provide multi-modal treatment, including a therapeutic milieu with community processes and structure, such as a level system and behavioral modification. The family should be involved in treatment, including social learning (e.g., parent training) and family therapy conjointly or without the patient present. The younger the patient, the more critical is the family's or other caretakers' involvement. If family treatment is not provided, the reasoning for its omission should be documented. Individual and group therapies should be included. An appropriate school program, including special education and vocational training, should be part of treatment. An individualized treatment plan should address specific treatment for comorbid disorders. Psychosocial skill and ego development programs, to improve social functioning (e.g., assertiveness, anger management) should be included if indicated. Treatment coordination with school, social services, and juvenile justice personnel should be ongoing, to assure timely and appropriate discharge to step-down facilities and return to the community.
REFERENCE
American Academy of Child and Adolescent Psychiatry (1997), Practice Parameters for the Assessment and Treatment of Children and Adolescents with Conduct Disorder. J Am Acad Child Adolesc Psychiatry, 36(10suppl)
