Clinical Psychiatry

Conduct-dissocial disorder

ICD-10F91Conduct disorders
DSM-5-TRF91.1Conduct Disorder, Childhood-Onset Type

1. Definition and nosology

Conduct-dissocial disorder (ICD-11: 6C91; DSM-5-TR: F91.1/F91.2/F91.9 Conduct Disorder, by onset type) — a persistent and repetitive pattern of violating the rights of others or age-appropriate social norms. Typically begins in childhood/adolescence; may transition to ASPD in adulthood.

2. History

  1. DSM-III (1980) — Official diagnosis.
  2. DSM-5 (2013) — “limited prosocial emotions” specifier (childhood marker of psychopathic traits).
  3. NICE CG158 (2017) — child and adolescent antisocial behavior.

3. Epidemiology

  • Prevalence: 12-month prevalence 2–10%, median 4%; higher in boys than in girls (DSM-5-TR).
  • Sex: 3 times higher in males.
  • Onset — childhood (before age 10, poor prognosis) or adolescence (age 10+, good prognosis).
  • Comorbidity: ADHD 50%, ODD, MDD, anxiety, substance use, learning disorders.

4. Etiology and pathogenesis

  • Heritability 40–60%.
  • Neurobiological — amygdala, prefrontal dysregulation, low sympathetic arousal.
  • Environment — childhood trauma, harsh parenting, family dysfunction, peers.
  • Prenatal — tobacco, alcohol.

5. Clinical features

DSM-5-TR 15 symptoms in 4 categories (≥ 3 symptoms in 12 months)

  • Aggression — towards people/animals: threat, assault, use of weapons, physical violence, sexual violence.
  • Object injury: Intentional arson, damage to other objects.
  • Deception/theft: Breaking and entering, lying, theft.
  • Serious rule violation: Staying out at night despite prohibition, running away from home, truancy.

“Limited prosocial emotions” qualifier (psychopathic traits)

  • Lack of remorse or guilt;
  • Lack of concern about performance (education, work);
  • Callous lack of empathy;
  • Shallow affect.

6. Diagnosis

6.1 Unified diagnostic criteria

DSM-5-TR criteria (≥ 3 symptoms from 15 in 12 months; at least 1 symptom in the last 6 months). Severity: mild, moderate, severe.

Onset: childhood type (≥1 symptom by age 10), adolescent type.

6.2 Differences between sources

  • DSM-5-TR and ICD-11 — both have the ‘limited prosocial emotions’ qualifier.
  • ICD-11 — ‘Conduct-Dissocial Disorder’; with childhood-onset and adolescent-onset types.
  • NICE CG158 — diagnosis and intervention in children and adolescents.

6.3 Diagnostic algorithm

  • Clinical interview + parent, teacher.
  • Structured interview (K-SADS).
  • CBCL (Child Behavior Checklist), TRF (Teacher Report Form).
  • The Inventory of Callous-Unemotional Traits — for psychopathic traits.
  • Comorbidity (ADHD, MDD, substance, learning).

6.4 Differential diagnosis

Condition Distinguishing feature
ODD (6C90) No serious legal violation.
ADHD (6A05) Impulsivity and attention; common comorbidity.
IED (6C73) Explosive type; absence of persistent antisocial pattern.
Manic episode Affective context.
RAD/DSED (6B44/6B45) Attachment disturbance since childhood.
Substance-induced Toxicology.

7. Examination and assessment

  1. CBCL, TRF, ICU.
  2. Comorbidity screening.
  3. Intellectual and academic assessment.

8. Treatment

8.1 General principles (NICE CG158 · AACAP)

  • Parent training programs first-line — for ages 3–11:
    1. Incredible Years (Webster-Stratton);
    2. PCIT (Parent-Child Interaction Therapy);
    3. Triple P.
  • For adolescents:
    • MST — Multisystemic Therapy (Henggeler S.W.) — encompassing family, peer, school, community;
    • FFT — Functional Family Therapy;
    • MTFC — Multidimensional Treatment Foster Care.
  • Comorbid ADHD — stimulant (also reduces aggression).
  • Antipsychotic (risperidone) — off-label in severe aggression, with caution; no FDA approval specifically for childhood aggression.
  • “Scared Straight” and similar programs are contraindicated — Cochrane (Petrosino A. 2013) — these programs increase antisocial behavior.
  • Boot-camp-style “tough love” programs — no evidence, harmful.

8.2 Treatment methods

  • “Incredible Years” program — Webster-Stratton — group program for parents of children aged 3–8 years; 14–22 sessions.
  • Parent-Child Interaction Therapy (PCIT) — 2–7 years; CDI + PDI.
  • Multisystemic Therapy (MST) — Home-based multisystem intervention for adolescents; evidence base strong for severe behavioral disturbances.
  • Functional Family Therapy (FFT) — Family-based, 8–30 sessions.
  • Multidimensional Treatment Foster Care (MTFC) — Structured fostering program; for severe cases.

8.3 Differences between sources

  1. National Institute for Health and Care Excellence (NICE). Clinical guideline CG158. 2017.
  2. AACAP Practice Parameter (Steiner H. 2007).
  3. Cochrane (Petrosino 2013) — Scared Straight is counterproductive.

9. Prognosis

  • With childhood-type and psychopathic traits — risk of ASPD in adulthood ~40–50%.
  • Adolescent-type good prognosis.
  • Early parent training and multisystem intervention significantly improve outcomes.

10. Myths and misconceptions

Myth 1: “Harsh punishment/discipline is the most effective intervention”

Evidence: Harsh punishment strengthens antisocial behavior; positive parenting training is evidence-based.

Myth 2: “‘Scared Straight’ programs ‘correct’ youth”

Evidence: Petrosino A. Cochrane 2013 — Scared Straight increases antisocial behavior (OR 1.68; 95% CI 1.20–2.36); contraindicated; sometimes presented as “effective” in media, but meta-analysis negative.

Myth 3: “Conduct disorder inevitably turns into ASPD”

Evidence: Approximately 50% of cases with adolescent-onset type remit; childhood-onset type and psychopathic traits indicate a poor prognosis.

Myth 4: “Stimulants increase aggression”

Evidence: In comorbid ADHD, stimulants reduce aggression; use with monitoring of behavior and adverse effects.

Myth 5: “Boot camp or military environment cures severe CD”

Evidence: No evidence; some studies show counterproductive effects.

Myth 6: “Antipsychotics are standard first-line treatment”

Evidence: parent training and psychosocial approaches first-line; risperidone off-label in severe refractory cases.

11. Sources

  • WHO. ICD-11. 6C91 Conduct-dissocial disorder. 2024.
  • APA. DSM-5-TR. 2022.
  • NICE CG158. Antisocial behavior and conduct disorders in children and young people: recognition and management. 2017.
  • Steiner H., Remsing L. AACAP Practice Parameter for the Assessment and Treatment of Oppositional Defiant Disorder. J Am Acad Child Adolesc Psychiatry 2007;46(1):126–141.
  • Petrosino A. et al. “Scared Straight” and other juvenile awareness programs for preventing juvenile delinquency. Cochrane Database Syst Rev 2013;(4):CD002796.
  • Henggeler S.W. Multisystemic Therapy. Guilford Press; 1998.
  • Sanders M.R. Development, evaluation, and multinational dissemination of the Triple P-Positive Parenting Program. Annu Rev Clin Psychol 2012;8:345–379.