What Is Conduct Disorder?

If your child is repeatedly misbehaving in a manner that is harming others, you might have been told that they have a condition called conduct disorder. 

By definition, conduct disorder is a pattern of behavior in which a child repeatedly, and intentionally, violates the basic rights of others and breaks social norms and rules. That doesn’t mean that all kids who are aggressive or defiant have conduct disorder, though they may be labeled with it.

There are lots of children who have big problem behaviors that don’t fit the conduct disorder pattern, says Stephanie Lee, PsyD, a clinical psychologist who treats kids with behavior problems. They could be impulsive, or anxious, or not be able to manage big feelings.

“It’s important to understand that only a small percentage of kids with conduct problems actually have a conduct disorder,” says Paul Frick, PhD, who studies CD at Louisiana State University.

Conduct disorder (CD) is a condition that affects about two to three percent of the population, can be diagnosed at any age and is more commonly found in boys. Children might be diagnosed with CD if:

• They are aggressive towards people or animals
• They destroy property
• They steal
• They regularly defy rules
• Their behaviors are so significant that they impact the child’s education and social life

Of the small percentage of children who actually have this condition, Dr. Frick estimates that about 10 percent — so less than one percent of the population — have conduct disorder with what are called “callous-unemotional traits.” This condition is diagnosed when children don’t develop the same level of empathy, guilt and other aspects of conscience as other children their age.

Children diagnosed with conduct disorder with callous-unemotional traits — also called “limited prosocial emotions” — are often described as cold and uncaring. They lack empathy and are more concerned about how their actions impact themselves, even if what they’ve done would harm another living being.

Parents of these children say their child will do whatever it takes to get what they want – such as lie, steal or physically harm someone – with no remorse. Researchers have found that there are some early indicators that a child may have a conduct disorder with callous-unemotional traits.

“There are some unusual social and emotional behaviors that signal something is different in the way this child’s brain may be developing,” explains Abigail Marsh, PhD, who studies this topic as an assistant professor at Georgetown University. “As preschoolers, they often display an unusual fearlessness or insensitivity to things that make most children a little bit worried or nervous, like the dark, heights or dogs. They demonstrate a surprising lack of responsiveness to typically scary things. For example, a parent once told me that her child liked to play in their very dark, creepy basement – a place no other kid would even go near.”

Other indications that a child may have conduct disorder with callous-unemotional traits include:

• They have a high threshold for pain
• They do not respond to some social cues and are only interested in connecting with others if it benefits them
• They do not seek physical affection and are not terribly affectionate to others
• They are not motivated by rewards for good behavior
• They are not afraid of punishment

Experts, including Dr. Marsh and Dr. Frick, recognize callous-unemotional traits as early warning signs that can place a child a risk for a number of problematic outcomes as adults, such as psychopathic personality, antisocial personality disorder, and aggression. They emphasize the importance of recognizing this pattern of traits as early as possible, ideally in children, to increase the chances of successful treatment and prevent more serious adult outcomes. But they strongly caution against applying terms like “psychopath” to children, arguing that it can be stigmatizing and dangerous. 

When a child is repeatedly misbehaving and doesn’t seem to care, it doesn’t automatically mean they have CD or CD with callous-unemotional traits.

Dr. Lee explains that when a child has serious behavior problems and clinicians aren’t yet sure what’s going on, they may use a diagnosis called disruptive behavior disorder not otherwise specified, or DBD-NOS. But when that diagnosis is given as a basis for services, it may be labeled by an insurance company as a form of conduct disorder. And when schools or authorities see that, they interpret the diagnosis as conduct disorder.

This is important to note because misdiagnosing a child with conduct disorder can have harmful consequences, especially for children of color.

There is a lot of stigma attached to conduct disorder, Dr. Lee notes. And it can be challenging for kids with the disorder to get care, because many providers don’t offer services to kids with the CD diagnosis. They may be wary of working with these kids because of potential legal liability if a child they’re treating hurts someone or engages in other dangerous acts.  

In addition, when a child is incorrectly diagnosed with CD, they don’t receive effective treatment for the issues they do have, which might be emotional dysregulation or anxiety or impulsivity, and they won’t learn how to manage their behavior. This, along with the stigma associated with CD, increases their risk of incarceration.

Dr. Frick says there are key differences between a child who has callous-unemotional traits and one who just has big problem behaviors. The former’s behaviors are often premeditated and done to intimidate others. The latter are acting out for some other reason and accidentally hurting someone in the process. To illustrate, Dr. Frick shares the story of two young boys who were referred to him for cruelty to animals. One boy shot a cat out of a tree and the other cut a cat.

“The boy who shot the cat out of the tree was trying to scare the cat down from the tree,” Dr. Frick recalls. “He used his dad’s gun to shoot around the cat, hoping to scare the cat into coming down. In the process, he accidentally shot the cat. His actions were impulsive – that was a very dangerous way to get a cat out of a tree, and he should have known he could have hurt somebody, including the cat.”

On the other hand, Dr. Frick says, “When I spoke to the boy who was cutting the cat, he said to me, ‘Oh, yeah, I’ve been doing this for a long time – I’m a scientist just like you. I want to see what happens and how the cat reacts as I cut more and more its tail. You should have seen the look in the cat’s eyes when I cut its tail!’ ”

While both children harmed cats, he concluded, one was done impulsively, without thinking, and the other was callous, not caring about what he was doing to the cat.

Understanding why the child is behaving in a given way is the key to proper diagnosis. Dr. Lee notes that parents are sometimes too quick to jump to the conclusion that their child, or another child, has conduct disorder when the behavior is really the symptom of another condition.

Children with behavior problems often respond well to positive reinforcement for desired behaviors, and appropriate consequences for undesired behaviors. Parent training programs teach parents to be consistent in rewarding kids for behaviors they want to encourage as well as in their consequences for those they want to discourage.

Rewarding children for good behavior needs to be, as Dr. Lee puts it, “big, bold and immediate.”

By giving them positive attention when they do something well, they’re likely to do it again.

Drs. Frick and Marsh are currently studying whether or not children with conduct disorder with callous-unemotional traits can be treated in a similar, yet more intense, manner. They call this “warm, responsive parenting.”

A parent training program called parent-child interaction therapy (PCIT) has been customized for children with CD and callous-unemotional traits by Eva Kimonis, PhD, who is a professor at the University of New South Wales in Australia. In PCIT, a therapist coaches the parent as they interact with the child, teaching them the skills they need to create positive interactions.

Rewards for kids with callous-unemotional traits
 Children with callous-unemotional traits don’t typically respond to positive social feedback, Dr. Marsh notes. “So, they don’t develop the sense that other people and relationships are intrinsically rewarding. They don’t learn that they need to work to maintain relationships and try not to damage them.”

In theory, she adds, that can be changed, so they can come to view social relationships as intrinsically rewarding. “The approach is to use really big, positive social reinforcement. A little smile isn’t going do it. Instead, there must be big positive emotions with a lot of warmth and even high fives. But it takes training. Parents need to work with a clinician who can help them apply them in a way that will be effective.”

Consequences for kids with callous-unemotional traits

In addition to even bigger rewards, parents of kids with CU need to use consequences for undesired behaviors that are specifically tailored to them.

“Punishments are designed to reduce a behavior, but parents often implement consequences that don’t actually end up being very punishing,” Dr. Lee explains. “That won’t really make the behavior go away.”

When disciplining a child diagnosed with conduct disorder with callous-unemotional traits, you can’t induce them to change their behavior because they’re hurting someone’s feelings, will lose friends, or get in trouble. It won’t work.

“Instead of saying, ‘If you do this, you’re going to hurt your brother’s feelings,’ you need to say, ‘If you do this, you’re going to lose iPad time for 30 minutes because you’re hurting your brother’s feelings and that’s disruptive to the family,’ ” Dr. Lee recommends.

And, according to Dr. Frick, you need to convince them that changing their behavior is in their own self-interest. “Many parents think that if they can find a better punishment, their child will see the error of their ways — that won’t work,” he says. “But, when you point out that their behaviors don’t seem to be working for them and they’re not getting what they want, then they may be interested in changing.”

We know that parent training like PCIT works for some kids who have been diagnosed with CD, though Dr. Lee notes that some of them may have been misdiagnosed with the disorder. We don’t yet know if it works for kids with callous-unemotional traits. There is anecdotal evidence of some success, but so far there isn’t enough data to show that it’s effective, and Dr. Lee, again, expresses concern that kids who have gotten better with the modified PCIT may be kids who don’t really have the disorder. However, Drs. Frick and Kimonis have applied for funding to conduct a controlled trial of the intervention. It could be an important breakthrough in the perception of kids with callous-unemotional traits, as well as a big help to those kids and their families.