Brief Literature Review on Conduct Disorder in Childhood

Conduct Disorder is included in the Disruptive, Impulse-Control, and Conduct Disorders category in DSM-5 for its feature of a repetitive and persistent pattern of behavior violating basic rights of others or age-appropriate societal norms (American Psychiatric Association, 2022). DSM-5 compartmentalizes its diagnostic criteria into 4 major behavioral categories: firstly, aggression to people and animals, including bullying, threatening, initiating fights, using weapons, physical cruelty to people and or animals, mugging, and forced sexual activity; secondly, destruction of property such as deliberate fire setting with intent to cause damage and destroying others’ property; thirdly, deceitfulness or theft involving breaking and entering, lying to obtain goods or avoid obligations, shoplifting and forgery; last but not least, serious violations of rules characteriszed as staying out at night despite parental prohibition (before age 13), running away overnight (at least twice), and truancy (before age 13) (APA, 2022). These symptoms may vary with age, with less severe behaviors emerging first (e.g., lying & shoplifting) and more severe behaviors emerging later (e.g., assault & rape) (APA, 2022).

The onset of age also varies, being indicated as 3 categories: childhood-onset, adolescent-onset and unspecified-onset (insufficient information about symptom onset); the current paper will primarily focus on the childhood-onset, which exists predominantly in males, appears more aggressive and is often preceded by ODD; it is frequently comorbid with ADHD with worse prognosis and higher risk of persistence into adulthood compared to adolescent-onset (APA, 2022). Interestingly, in addition to the severity ratings from mild to severe, APA (2022) also identified a limited prosocial emotions specifier, in which a minority of youth present with callous-unemotional traits, including a lack of remorse/guilt or empathy, unconcern about performance, and shallow affect. This specifier is specifically associated with childhood-onset type and more severe presentations, as exhibited in individuals who are more likely to display planned aggression. With this feature, the manifestation in childhood is of significant clinical concern due to its association with a more severe and persistent trajectory of antisocial behavior into adolescence and adulthood (Moffitt, 2018; Mohan et al., 2023). When it comes to the course of development, although the majority tend to remit by adulthood, childhood-onset Conduct Disorder has been linked to poorer psychosocial outcomes, including academic difficulties, substance use, and increased risk for involvement with the juvenile justice system (Moffitt, 2018; Odgers et al., 2008).

Prevalence estimates of Conduct Disorder vary widely, typically ranging from 2% to 10% in the general population, with higher rates reported among boys than girls (APA, 2022). However, these estimates must be interpreted with caution, as substantial evidence indicates that diagnostic practices are influenced by systemic biases (Ghandour et al., 2019). Racial and ethnic minority children, particularly Black and Latino boys, are disproportionately labeled with conduct-related disorders and are more likely to encounter punitive disciplinary systems rather than receive appropriate mental health interventions (Ghandour et al., 2019). 

Etiology (Bio-Psycho-Social Model) of Conduct Disorder

Early behavioral patterns are often shaped by the interaction of biological predispositions and environmental influences. Biological factors appear to play an important role in Conduct Disorder, with studies indicating a moderate heritable component for antisocial behavior, impulsivity, temperament, aggression, and reduced sensitivity to punishment (Mohan et al., 2023). According to Moffitt (2018), life-course persistent offenders whose onset starts in early childhood are influenced more strongly by genetic traits such as low verbal ability and low self-control; genetics also influences aggressive symptoms much more strongly. Conduct Disorder is also significantly associated with Polygenic Risk Scores for ADHD, Major Depressive Disorder, and Autism Spectrum Disorder, suggesting that the clinical overlap between these conditions is partially driven by a shared genetic architecture (Tesli et al., 2024). High levels of maternal stress during pregnancy and maternal smoking were identified as consistent risk factors for the development of disruptive behavior disorders (Elbagir et al., 2023). Preterm birth and low birth weight were also shown to have a population-level impact on the prevalence of developmental and behavioral disabilities (Elbagir et al., 2023). Research also suggests that low levels of dopamine and elevated testosterone levels have been linked to increased aggression (Mohan et al., 2023). Among the childhood-onset individuals, there are also abnormalities in the frontotemporal-limbic brain areas, such as the ventral prefrontal cortex and amygdala, which are responsible for affect regulation and processing; specifically, there is reduced autonomic fear conditioning in these individuals (Moffitt, 2018). 

Parental and family factors also play a substantial role in the development of Conduct Disorder. A home environment marked by poor structure, inadequate supervision, frequent marital conflict, and inconsistent discipline can contribute to maladaptive behaviors in children (Mohan et al., 2023; Odgers et al., 2008). Harsh parenting practices, including verbal abuse and physical aggression, as well as exposure to domestic violence, can further increase the risk (Mohan et al., 2023; Odgers et al., 2008). In addition, a family history of criminal behavior or disruptive behavior in caregivers, parental substance abuse such as alcohol dependence, low parental education, and living in low social or economic conditions marked by overcrowding and unemployment can create chronic stress and reduce effective parenting, all of which may contribute to conduct problems (Elbagir et al., 2023; Mohan et al., 2023; Odgers et al., 2008).

School-related factors can further contribute to Conduct Disorder. A school environment with large class sizes, a high student-to-teacher ratio, and limited positive feedback from teachers may increase the risk of behavioral problems (Mohan et al., 2023). In addition, a lack of supportive staff and counseling services to help children cope with socioeconomic difficulties can leave important children’s needs unaddressed (Mohan et al., 2023). Exposure to gang violence in the surrounding community may further reinforce aggressive or antisocial behavior (Mohan et al., 2023). Importantly, bullying is another significant environmental risk factor strongly associated with the diagnosis (Tesli et al., 2024). 

Additionally, Elbagir et al. (2023) also pointed out that lifestyle habits in early adolescence can correlate with behavioral symptoms: Frequent consumption of energy drinks and high coffee intake among early adolescents is significantly correlated with higher scores on psychopathology scales linked to increased impulsivity and sensation-seeking, which are the main components of CD and ADHD. 

In general, research on gene-environment interaction reveals that although genetics play a significant part in Conduct Disorder, the genetic predisposition toward aggression may only lead to actual antisocial behavior if the child is also exposed to harsh parenting or neighborhood disadvantage (Burt, 2022). It is also worth noting that a child’s genes can actually influence the environments they experience: for example, a child’s genetically influenced temperament, such as irritability, might evoke harsher discipline from parents; as youth get older, they may seek out “delinquent peers” that match their own behavioral tendencies (Burt, 2022). Burt’s study (2022) further notes that genetic influences tend to become more pronounced as individuals gain more autonomy to select their own environments, making the environment a critical moderator of risk (Burt, 2022). 

Diverse and Cultural Considerations

There are conspicuous gender differences in children who are diagnosed with CD. Males show significantly higher conduct problems at most ages, but the difference is smallest at age 15 (APA, 2022); Odgers et al. (2008) proposed that this might be due to the fact that girls have lower rates of the neurodevelopmental risk factors that drive the life-course persistent symptoms. Regarding the expression of symptoms, males tend to exhibit more overt physical aggression, such as fighting and property destruction, whereas females are more likely to engage in relational aggression, such as involvement in abusive relationships and substance use (Odgers et al., 2008). 

There have been emerging concerns regarding the overdiagnosis of CD in non-Hispanic Black children relative to White peers, which may mask other co-occurring mental health conditions like trauma, ADHD, and substance use disorders (Brown et al., 2024). According to Weinberger (2023), BIPOC youth were more likely to belong to an early-onset persistent conduct problem trajectory compared to White peers, which entails more serious behavioral issues. Furthermore, BIPOC youth who are more frequently diagnosed with conduct problems tend to experience worse outcomes compared to White peers, including increased rates of out-of-school suspensions, expulsions, and criminal legal-system involvement (Weinberger, 2023). The risk of the trajectory might be worsened when compounded with racial discrimination (Weinberger, 2023). Social environments such as neighborhoods with high “collective efficacy” can act as a protective buffer, reducing the expression of risks (Burt, 2022; Weinberger, 2023). However, many clinicians tend to make assumptions about diagnosis rates based on stereotyped beliefs about certain ethnic groups rather than individual assessment, thus often interpreting disruptive and aggressive symptoms in African American children more negatively than their White American counterparts (Mizock & Harkins, 2011). The American Academy of Pediatrics found that 20-60% of juvenile detainees were diagnosed with CD, many of whom were adolescents of color and were more likely to receive formal prosecution and harsher treatment than White American detainees (Mizock & Harkins, 2011). What’s worse, both African Americans and Latino Americans have limited access to mental health care in general, which can contribute to poorer mental health care services once they are diagnosed with CD (Mizock & Harkins, 2011).

Relatively scarce research data addressed the connection between immigration and Conduct Disorder, and the existing data presented inconsistent results. Osooli et al. (2024) examined Conduct Disorder risk in first- and second-generation immigrant children and adolescents compared with native Swedish children, concluding that the adjusted risk was lower among first-generation immigrants and most second-generation immigrant groups compared with natives. Cultural differences in parenting styles may affect the risk of CD (Osooli et al., 2024). However, another study found lower CD risk in non-migrant households and higher risk in children of Mexican-born immigrants raised in the US, which might be caused by acculturation stress, intergenerational conflicts, racial marginalization, and the unique environmental factors in the U.S. contributing to the higher CD rates (Breslau et al., 2011).

It is important to note that Conduct Disorder and antisocial behaviors are cultural and context dependent, given that what is considered “rule-breaking” in one society or time period may be viewed differently in another, which can influence how these behaviors are tracked and studied (Burt, 2022). A behavior labeled as “a conduct problem” in one context may be normal, adaptive, or even necessary in another (Pinderhughes et al., 2017). For example, cultures emphasizing emotional suppression, such as Chinese and Thai cultures, may have lower thresholds for externalizing behaviors, potentially affecting parent reports and clinical recognition (Canino et al., 2010). Similarly, parenting practices also vary across cultures; what looks like “harsh parenting” in one culture may be normative or valued in another (Pinderhughes et al., 2017). As CD is closely tied to poverty, discrimination, and neighborhood context, behaviors associated with CD may reflect a child’s adaptive responses to adversity instead of pathology (Pinderhughes et al., 2017). 

Assessment Measures

One of the most commonly used structured diagnostic tools is the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS), which is a semi-structured interview used to assess psychiatric disorders in children and adolescents (Kaufman et al., 2016). The K-SADS systematically evaluates symptoms of CD while also screening for related disorders such as ADHD, ADD, anxiety, and mood disorders, all of which frequently co-occur with CD (Kaufman et al., 2016). Researchers proposed that ADHD and ODD are common developmental precursors or overlapping conditions in children with conduct problems (Kaufman et al., 2016). 

Conduct Disorder Rating Scale (CDRS) requires teachers and parents to assess CD symptoms in children. Specifically, the 19 items in the parents’ version and 13 items in the teachers’ version directly map onto the diagnostic criteria for CD while addressing the practical difficulties of traditional diagnostic interviews (Waschbusch & Elgar, 2007). Similarly, Conduct and Oppositional Defiant Disorder Scales (CODDS), which is a five-minute screening tool designed to provide a brief but valid proxy for DSM-5 diagnoses of ODD and CD, also proves to be highly clinically efficient (Raine et al., 2022).

Although the NICHQ Vanderbilt Assessment Scales are primarily used to diagnose ADHD in children, they also include sections for screening comorbid conditions such as anxiety, depression, ODD, and CD (Beck et al., 2012). The Disruptive Behavior Disorders Rating Scale (DBDRS) is another useful tool designed to assess the symptoms of ADHD, ODD, and CD in children (Fosco et al., 2023). The Child Behavior Checklist (CBCL) is an extensive 113-item parent-report questionnaire used to identify behavioral issues, such as rule-breaking behaviors and aggressive behaviors that indicate potential CD while assessing a richer background information (Yule et al., 2020). 

According to Szorady (2023), some neurophysiological measures, such as the P300 amplitude, show promise as early markers for conduct problems in children, as conduct problems were significantly and negatively correlated with P300 amplitude, with a smaller amplitude related to impaired cognitive functioning, worse school performance, occupational failure, and increased antisocial behavior risk. Additionally, given that CD symptoms occur across various settings such as the home, school, and community, and that different observers might report varied aspects of functioning, relying on one source alone can lead to incomplete or inaccurate conclusions; the best practice therefore would be to integrate clinical interviews, behavior rating scales, direct observation, developmental history, and assessment of comorbid conditions (APA, 2022; Szorady, 2023).

Evidence-Based Treatments

Conduct problems are among the most prevalent childhood mental health conditions (7.4%), yet they have the lowest treatment rate (53.5%) compared to depression (78.1%) and anxiety (59.3%) (Ghandour et al., 2019). Treatment disparities are particularly pronounced for low-income children, young children (age 3-5), and those with mild presentations (Ghandour et al., 2019). Protective factors can help reduce the likelihood or severity of Conduct Disorder: For example, having a positive role model in life, experiencing affectionate parenting, and developing the ability to regulate emotions through self-soothing all support healthier behavioral development (Mohan et al., 2023). Early intervention and adequate parenting are also important because they can address emerging problems before the symptoms progress more severely (Mohan et al., 2023).

As childhood-onset individuals often possess deficits in verbal learning and memory, higher rates of psychosis, a history of childhood maltreatment, and more serious violent behavior, it is important to tailor treatments according to age-specific traits while emphasizing the dual parent-physician relationships for more beneficial outcomes (Szorady, 2023). Since youth with CD often have language processing difficulties and struggle with abstract concepts, which hinders engagement with verbally intensive therapies, feedback-informed therapy involving both parents and teachers can also afford benefits in linguistic improvement in youth who previously lack these elements (Szorady, 2023). School-based early intervention programs can help reduce parent- and teacher-reported internalizing and externalizing symptoms (Szorady, 2023). Thus, school-based early intervention combined with parental involvement is vital for symptom management (Szorady, 2023).

There are multitudinous evidence-based psychosocial interventions for youth with conduct problems, and the intervention efficacy for each is developmentally dependent: parent-focused interventions are most effective for younger children under 11 years, while cognitive-behavioral and family-focused approaches yield greater benefits for older youth over 11 years, with multi-component programs showing moderate effectiveness across both age groups (Gatti, 2019). Parent Management Training, Problem-Solving Skills Training, Functional Family Therapy, and the Incredible Years Program represent among the most extensively researched and widely implemented programs with strong empirical support (Gatti, 2019). Parent management training focuses on equipping caregivers with strategies to implement discipline, reinforce positive behaviors, and promote prosocial development; multisystemic therapy extends this approach by targeting the child’s functioning across family, school, and community contexts to improve family dynamics, academic performance, and overall behavioral regulation; anger management training and individual psychotherapy further support the child by enhancing emotional regulation, strengthening problem-solving abilities, and fostering assertiveness skills to resist negative peer or community influences while improving interpersonal relationships (Mohan et al., 2023). In parallel, pharmacotherapy can also be incorporated to address comorbidities, such as stimulants and non-stimulants for ADHD, antidepressants for depression, and mood stabilizers (including antiepileptic drugs and second-generation antipsychotics) for aggression, mood dysregulation, and Bipolar Disorder (Mohan et al., 2023). However, given that the literature supporting psychopharmacological management of aggressive behavior remains insufficient to determine the comparative long-term risks and benefits in pediatric populations, psychotherapy should be justified as the first-line treatment (Gatti, 2019). 

However, findings also highlight systemic barriers: Families with low income or single parents cannot afford private assessment and treatment, while publicly funded resources have long waitlists that may worsen outcomes (Szorady, 2023). What’s more, since youth with childhood-onset CD tend to display more aggression than adolescent-onset CD, this creates a two-fold barrier: aggressive behavior may evoke negative emotions in parents and teachers, and clinicians insufficiently equipped to manage associated aggressive tendencies may abandon treatment, further damaging the child’s self-worth and wellbeing (Szorady, 2023).

Interestingly, utilizing VR to target transdiagnostic processes may be a more scalable and cost-effective alternative to traditional CD treatments for its innovative way of targeting emotion recognition and regulation deficits through immersive and gamified activities that youth find highly engaging, with data showing 100% preferring VR to traditional therapy (Thomson et al., 2025). Youth with CD typically disengage from verbally intensive treatments due to language processing difficulties and reduced sensitivity to social rewards, yet VR addresses these barriers through self-guided, interactive scenarios set in real-world contexts where youth can practice identifying emotions, managing triggers, and resolving conflicts in ways that transfer to actual social situations (Thomson et al., 2025).

Gaps in the Literature

The overwhelming majority of studies on CD diagnoses did not provide comprehensive data on race and ethnicity and co-occurring psychiatric disorders in children receiving diagnoses of CD, which presents s a critical gap in research that must be addressed to prevent perpetuating health inequities (Brown et al., 2024). Specifically, most research on callous-unemotional (CU) traits in CD has been conducted in North America, with limited cross-cultural investigation (Canino, 2010). Paucity of data particularly exists among Asian populations, and given that CD is shaped by multifarious factors, Asian populations are highly heterogeneous with distinct brain structural, genetic predisposition, environmental factors, and cultural practices; these characteristics can affect CD’s prevalence and clinical features (Amalia et al., 2024). What’s more, using only DSM diagnostic criteria may have obscured culturally specific expressions of psychopathology that are not captured by these symptom sets (Canino, 2010).

Moffitt (2018) proposed that the original taxonomy of the CD diagnosis was developed around traditional street offenses such as shoplifting, burglary, and vehicle theft, whereas many antisocial behaviors now occur online, including hacking, cyberbullying, harassment, fraud, and other forms of rule-breaking that may be more accessible to adolescents than conventional street crimes. As a result, future research should examine how the criteria also apply to digital misconduct and cybercrimes (Moffitt, 2018). 

Additionally, Salekin et al. (2025) proposed a Multispecifier Personality Model for Conduct Disorder, as the current diagnostic criteria include only the callous-unemotional (CU) specifier. The authors argue that the other two additional personality trait dimensions, the grandiose-manipulative (GM) and the daring-impulsive (DI) traits, should also be incorporated to further clarify CD conceptualization to improve our understanding of prevalence and etiology (Salekin et al., 2025). 

References 

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