CASE STUDY

Conduct disorder is a psychiatric category marked by a pattern of repetitive behavior wherein the rights of others or social norms are violated. Symptoms include verbal and physical aggression, cruel behavior toward people and pets, destructive behavior, lying, truancy, vandalism, and stealing.

Conduct disorder is a major public health problem because youths with conduct disorder not only inflict serious physical and psychological harm on others, but they are at greatly increased risk for incarceration, injury, depression, substance abuse, and death by homicide and suicide. After the age of 18, a conduct disorder may develop into antisocial personality disorder, which is related to psychopathy.

The diagnostic criteria for Conduct Disorder (codes 312.xx, with xx representing digits which vary depending upon the severity, onset, etc. of the disorder) as listed in the DSM-IV-TR are as follows:

1. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:
   1. Aggression to people and animals
      1. often bullies people, threatens, or intimidates others
      2. often initiates physical fights
      3. has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun) (except for activities such as archery and hunting)
      4. has been physically cruel to people
      5. has been physically cruel to animals
      6. has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
      7. has forced someone into sexual activity
   2. Destruction of property
      1. has deliberately engaged in fire setting with the intention of causing serious damage.
      2. has deliberately destroyed others' property (other than by fire).
   3. Deceitfulness or theft
      1. has broken into someone else's house, building, or car
      2. often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
      3. has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
   4. Serious violations of rules
      1. often stays out at night despite parental prohibitions, beginning before age 13 years
      2. has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
      3. is often truant from school, beginning before age 13 years
2. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
3. If the individual is age 18 years or older, criteria are not met for Antisocial personality disorder.

At one time or another most children and adolescents act out or do things that are destructive or troublesome to themselves or others. Only if such behavior persists is it indicative of conduct disorder. This disorder is much more common among boys than girls. As many as 50 percent of parents of 4- to 6-year-old children report that their child has exhibited some such behavior, but most such children show a decrease in antisocial behavior within the next couple of years.

Those in whom this behavior persists may be candidates for psychological help. It is estimated that 5 percent of children show serious conduct problems, being described as impulsive, overactive, and aggressive and engaging in delinquent behavior. Some motives for such behavior are genetic inheritance of a difficult temperament, ineffective parenting, and living in a neighborhood in which violence is common. There is a lack of consensus on what actually works, despite considerable efforts made to help children with conduct disorders.^[3]

A closely linked behavior is juvenile delinquency. This term refers to an adolescent's tendency to break the law or to engage in illicit behavior, a broad concept that ranges from littering to murder. According to U.S. government statistics, eight of ten cases of juvenile delinquency involve males. However, in the last two decades there has been a greater increase in female than male delinquency.

Juvenile delinquency has been found to vary among cultures. Delinquency rates among minority groups and lower-socioeconomic-status-youth are especially high in proportion to the overall population of these groups. However, such groups have less influence over the judicial decision-making process in the United States and may be judged delinquent more readily than their white counterparts and those of higher socioeconomic status. Some suggested causes of delinquency are heredity, identity problems, community influences, and family experiences.

Although delinquency is less exclusively a phenomenon of lower socioeconomic status than it has been in the past, some characteristics of lower-socioeconomic-class cultures may promote delinquency. It is a complex problem, but psychologists have found factors which may predict whether a youth is likely to turn violent. Violent youths are overwhelmingly male and driven by feelings of powerlessness. Ill-directed drives for power often motivate youth especially toward acts of violence.

Some scholars have proposed that lack of empathy and empathic concern (callous disregard for the welfare of others) is an important risk factor for conduct disorder.

Developmental psychologists and social neuroscientists have hypothesized that empathy and sympathetic concern for others are essential factors inhibiting aggression toward others.

The propensity for aggressive behavior has been hypothesized to reflect a blunted empathic response to the suffering of others.^[8] Such a lack of empathy in aggressive individuals may be a consequence of a failure to be aroused by the distress of others. Similarly, it has been suggested that aggressive behavior arises from abnormal processing of affective information, resulting in a deficiency in experiencing fear, empathy, and guilt, which in normally developing individuals inhibits the acting out of violent impulses.

Recently, a functional magnetic resonance imaging (fMRI) study conducted by neuroscientist Jean Decety and colleagues at the University of Chicago reported that youth with aggressive conduct disorder (who have psychopathic tendencies) have a different hemodynamic brain response when confronted with empathy-eliciting stimuli. In the study, researchers compared 16- to 18-year-old boys with aggressive conduct disorder to a control group of adolescent boys with no unusual signs of aggression.

The youth with the conduct disorder had exhibited disruptive behavior such as starting a fight, using a weapon and stealing after confronting a victim. The youth were tested with fMRI while looking at video clips in which people endured pain accidentally, such as when a heavy bowl was dropped on their hands, and intentionally, such as when a person stepped on another's foot. Results show that the aggressive youth activated the neural circuits underpinning pain processing to the same extent, and in some cases, even more so than the control participants without conduct disorder.

However, aggressive adolescents showed a specific and very strong activation of the amygdala and ventral striatum (an area that responds to feeling rewarded) when watching pain inflicted on others, which suggested that they enjoyed watching pain. Unlike the control group, the youth with conduct disorder did not activate the areas of the brain involved in understanding social interaction and moral reasoning (i.e., the paracingulate cortex and temporoparietal junction).

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