Most children break rules or misbehave on occasion. If they consistently display extreme hostility and defiance, however, they may qualify for a diagnosis of oppositional defiant disorder or conduct disorder. Those with oppositional defiant disorder are argumentative and defiant, angry, and irritable, and in some cases, vindictive (APA, 2013). They may argue repeatedly with adults, ignore adult rules and requests, deliberately annoy other people, and feel much anger and resentment. As many as 10 percent of children qualify for a diagnosis of oppositional defiant disorder (Mash & Wolfe, 2012; Merikangas et al., 2010). The disorder is more common in boys than in girls before puberty but equal in both sexes after puberty.

Children with conduct disorder, a more severe problem, repeatedly violate the basic rights of others (APA, 2013). They are often aggressive and may be physically cruel to people or animals, deliberately destroy other people’s property, steal or lie, skip school, or run away from home (see Table 17-3). Many threaten or harm their victims, committing such crimes as firesetting, shoplifting, forgery, breaking into buildings or cars, mugging, and armed robbery. As they get older, their acts of physical violence may include rape or, in rare cases, homicide. The symptoms of conduct disorder are apparent in this summary of a clinical interview with a 15-year-old boy named Derek:

Conduct disorder usually begins between 7 and 15 years of age (APA, 2013). As many as 10 percent of children, three-quarters of them boys, qualify for this diagnosis (Mash & Wolfe, 2012; Hibbs & Jensen, 2005). Children with a relatively mild conduct disorder often improve over time, but a severe case may continue into adulthood and develop into antisocial personality disorder or other psychological problems (Mash & Wolfe, 2012). Usually, the earlier the onset of the conduct disorder, the poorer the eventual outcome. Research indicates that more than 80 percent of those who develop conduct disorder first display a pattern of oppositional defiant disorder (APA, 2013; Lahey, 2008). More than one-third of children with conduct disorder also display attention-deficit/hyperactivity disorder (ADHD), a disorder that you will read about shortly (Jiron, 2010). And a number of children with the disorder also experience depression and anxiety.

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Some clinical theorists believe that there are actually several kinds of conduct disorder, including (1) the overt-destructive pattern, in which individuals display openly aggressive and confrontational behaviors; (2) the overt-nondestructive pattern, dominated by openly offensive but nonconfrontational behaviors such as lying; (3) the covert-destructive pattern, characterized by secretive destructive behaviors such as violating other people’s property, breaking and entering, and setting fires; and (4) the covert-nondestructive pattern, in which individuals secretly commit nonaggressive behaviors, such as being truant from school (McMahon et al., 2010; McMahon & Frick, 2007, 2005). It may be that the different patterns have different causes. In a similar vein, DSM-5 instructs diagnosticians to distinguish those individuals whose conduct disorder is marked by particularly callous and unemotional behaviors, as they may be qualitatively different from others with the disorder (APA, 2013).

Other researchers distinguish yet another pattern of aggression found in certain cases of conduct disorder, relational aggression, in which the individual is socially isolated and primarily engages in social misdeeds such as slandering others, spreading rumors, and manipulating friendships (Ostrov et al., 2014; Keenan et al., 2010) (see MediaSpeak below). Relational aggression is more common among girls than boys.

Many children with conduct disorder are suspended from school, placed in foster homes, or incarcerated (Weyandt et al., 2011). When children between the ages of 8 and 18 break the law, the legal system often labels them juvenile delinquents (Wiklund et al., 2014; Jiron, 2010). More than half of the juveniles who are arrested each year are recidivists, meaning they have a history of having been arrested. Boys are much more involved in juvenile crime than girls, although the gap between them is narrowing. Girls are most likely to be arrested for drug use, sexual offenses, and running away, boys for drug use and crimes against property. After steadily rising during the 1990s, the number of arrests of teenagers for serious crimes has fallen by one-third during the past decade (U.S. Department of Justice, 2014, 2010).

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Many cases of conduct disorder, particularly those marked by destructive behaviors, have been linked to genetic and biological factors (Kerekes et al., 2014; Wallace et al., 2014). In addition, a number of cases have been tied to drug abuse, poverty, traumatic events, and exposure to violent peers or community violence (Wymbs et al., 2014; Weyandt et al., 2011). Most often, however, conduct disorder has been tied to troubled parent–child relationships, inadequate parenting, family conflict, marital conflict, and family hostility (Henggeler & Sheidow, 2012; Mash & Wolfe, 2012). Children whose parents reject, leave, coerce, or abuse them or fail to provide appropriate and consistent supervision are apparently more likely to develop conduct problems. Children also seem more prone to this disorder when their parents themselves are antisocial, display excessive anger, or have substance use, mood, or schizophrenic disorders (Advokat et al., 2014).

Because aggressive behaviors become more locked in with age, treatments for conduct disorder are generally most effective with children younger than 13 (APA, 2013; Webster-Stratton & Reid, 2010). A number of interventions, from sociocultural to child-focused, have been developed in recent years to treat children with the disorder. As you will see, several of these have had modest (and at times moderate) success, but clearly no one of them alone is the answer for this difficult problem. Today’s clinicians are increasingly combining several approaches into a wide-ranging treatment program.

Sociocultural TreatmentsGiven the importance of family factors in conduct disorder, therapists often use family interventions. One such approach, used with preschoolers, is called parent-child interaction therapy (Hembree-Kigin & McNeil, 2013; Zisser & Eyberg, 2010; Querido & Eyberg, 2005). Here therapists teach parents to work with their child positively, to set appropriate limits, to act consistently, to be fair in their discipline decisions, and to establish more appropriate expectations regarding the child. The therapists also try to teach the child better social skills. Ideally, these efforts strengthen the relationship between the parents and child, improve the parents’ attitudes, lead to more parent control, and help bring about improvements in the child’s behavior. A related family intervention for very young children, video modeling, works toward the same goals with the help of video tools (Webster-Stratton & Reid, 2010; Webster-Stratton, 2005).

When children reach school age, therapists often use a family intervention called parent management training. In this approach, (1) parents are again taught more effective ways to deal with their children, and (2) parents and children meet together in behavior-oriented family therapy (Kazdin, 2012, 2010, 2002; Forgatch & Patterson, 2010). Typically, the family and therapist target particular behaviors for change; then, with the help of written manuals, therapy rehearsals and practice, and homework, the parents are taught how to better identify problem behaviors, stop rewarding unwanted behaviors, and reward proper behaviors in a consistent manner. Like the family interventions for preschool-age children, parent management training has often achieved a measure of success (Kazdin, 2012; Forgatch & Patterson, 2010; McMahon & Kotler, 2008).

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Other sociocultural approaches, such as residential treatment in the community and programs at school, have also helped some children improve. In one such approach, treatment foster care, delinquent boys and girls with conduct disorder are assigned to a foster home in the community by the juvenile justice system (Henggeler & Sheidow, 2012). While there, the children, foster parents, and birth parents all receive training and treatment interventions, including family therapy with both sets of parents, individual treatment for the child, and meetings with the school and with parole and probation officers. In addition, the children and their parents continue to receive treatment and support after they leave foster care. This program is apparently most beneficial when all the intervention components are applied simultaneously.

In contrast to these sociocultural interventions, institutionalization in so-called juvenile training centers has not met with much success (Stahlberg et al., 2010; Heilbrun et al., 2005). In fact, such institutions frequently serve to strengthen delinquent behavior rather than resocialize young offenders.

Child-Focused TreatmentsTreatments that focus primarily on the child with conduct disorder, particularly cognitive-behavioral interventions, have had some success in recent years (Kazdin, 2012, 2010, 2007). In an approach called problem-solving skills training, therapists combine modeling, practice, role-playing, and systematic rewards to help teach children constructive thinking and positive social behaviors. During therapy sessions, the therapists may play games and solve tasks with the children, and later help the children apply the lessons and skills derived from the games and tasks to real-life situations.

In another child-focused approach, the Coping Power Program, children with conduct problems participate in group sessions that teach them to manage their anger more effectively, view situations in perspective, solve problems, become aware of their emotions, build social skills, set goals, and handle peer pressure. Studies indicate that child-focused approaches such as these do indeed help reduce aggressive behaviors and prevent substance use in adolescence (Lochman et al., 2011, 2010).

Recently, drug therapy has also been used for children with conduct disorder. Studies suggest that stimulant drugs may be helpful in reducing their aggressive behaviors at home and at school (Levy & Bloch, 2012; Connor et al., 2002).

PreventionIt may be that the best hope for dealing with the problem of conduct disorder lies in prevention programs that begin in the earliest stages of childhood (Hektner et al., 2014; Boxer & Frick, 2008). These programs try to change unfavorable social conditions before a conduct disorder is able to develop. The programs may offer training opportunities for young people, recreational facilities, and health care, and may try to ease the stresses of poverty and improve parents’ child-rearing skills. All such approaches work best when they educate and involve the family.

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