Conduct disorder

Conduct disorder (CD) matters on case exams because it changes risk, onset prognosis, and the line to antisocial personality disorder. The counselor must recognize when behavior crosses from defiance into violating others' basic rights or major age-appropriate norms.

Criteria at exam depth (paraphrased). A repetitive, persistent pattern with at least 3 of 15 behaviors in the past 12 months, at least one in the past 6 months, from four categories:

• Aggression to people and animals: bullying or intimidating, starting fights, using a weapon that can cause serious harm, physical cruelty to people or to animals, stealing while confronting a victim, forcing sexual activity.
• Destruction of property: deliberate fire-setting intended to cause damage, or other deliberate destruction.
• Deceitfulness or theft: breaking into a house, building or car; lying to obtain goods or avoid obligations ("conning"); stealing without confronting a victim.
• Serious rule violations: staying out at night against parental rules beginning before age 13, running away overnight (at least twice, or once for a lengthy period), truancy beginning before age 13.

The pattern causes significant impairment. If the person is 18 or older, criteria for ASPD are not met.

Specifiers.

• Childhood-onset: at least one symptom before age 10. Adolescent-onset: no symptoms before 10. Unspecified onset when unknown. Childhood onset carries the poorer prognosis.
• With limited prosocial emotions: at least 2 of lack of remorse or guilt, callous lack of empathy, unconcern about performance, and shallow or deficient affect, shown persistently over at least 12 months across relationships and settings.
• Severity: mild, moderate, severe.

Hinge differentials.

• ODD: defiance and irritability without aggression, destruction, theft or serious rule violations.
• ASPD: diagnosed only at 18+ and requires conduct disorder evidence with onset before age 15.
• ADHD: impulsive rule-breaking without violation of others' rights; often co-occurs.
• Bipolar disorder: aggression confined to mood episodes.
• Adjustment disorder / context reaction: isolated acts after a stressor, not a repetitive pattern.

On the NCMHCE. Collateral from school, family and juvenile justice records is central; collateral shows whether the pattern is repetitive and cross-setting and when it began (before or after age 10). Screen for violence risk, weapons, abuse and neglect, substance use, and suicide risk. Mandated reporting may apply when the youth is a victim. First-line approaches are family- and system-based: parent management training for younger children, and multisystemic or family therapies plus CBT problem-solving for adolescents. Watch for bias in labeling youth of color or youth in high-adversity environments where behavior may be protective.

Clinical Pearl: 3 of 15 in 12 months, 1 in the past 6; onset split at age 10. ASPD needs age 18+ plus CD before 15.