Oppositional Defiant Disorder

Conduct Disorder in Teens with ADHD: Signs, Symptoms, Interventions

In extreme cases, ADHD is accompanied by conduct disorder — a disruptive behavior disorder marked by resisting rules, defying authority, and demonstrating physical aggression. Here, learn more about the signs, symptoms, and treatment for this disruptive behavior disorder in teens with ADHD.

Family conflict - child throwing tantrum at tired mother. Sad parent angry at naughty kid with bad behavior, cartoon sketch style hand drawn vector illustration isolated on white background.
Family conflict - child throwing tantrum at tired mother. Sad parent angry at naughty kid with bad behavior, cartoon sketch style hand drawn vector illustration isolated on white background.

What Is Conduct Disorder?

All children are sometimes angry or defiant when upset; they will argue and test limits as normal steps in the separation and individuation process. Children with attention deficit hyperactivity disorder (ADHD or ADD) exhibit these behaviors more often than those without ADHD. But when the behaviors become frequent and severe, they may indicate an emerging disruptive behavior disorder like Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD).

It’s difficult to distinguish between ODD and CD — both predominantly male disorders that revolve around problems with self-control. Both also involve disobedience, resisting rules, and defying authority. These children tend to be angry and spiteful, and they blame others rather than accept responsibility for their actions.

Many experts consider the two disorders on a continuum, with CD being a more severe version of ODD. Indeed, most children with CD have previously had an ODD diagnosis. The escalation from ODD to CD involves increasing physical aggression and violations of others’ rights. Although both disorders often resolve before adulthood, the outcomes for CD tend to be poorer than for those with ODD.

Conduct Disorder and ADHD in Teens

ADHD is difficult to manage on its own; it is even harder to handle in conjunction with co-existing disorders. Roughly half of all children with ADHD will also develop ODD or CD. The prevalence of co-occurring CD increases with age and the disorder may affect as many as 50 percent of teens with ADHD. Likewise, about 60 percent of teens with CD also have co-occurring ADHD. CD is most likely to develop in those with severe ADHD symptoms. Those with both disorders tend to experience an earlier age of symptom onset, more severe symptoms, and more emotional and psychiatric problems than those with just ADHD or CD.

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Types of Conduct Disorder

The CD diagnosis specifies subtypes based on age of onset, with child symptoms presenting before age 10, and adolescent symptoms defined as appearing after age 10. Those with child onset symptoms, sometimes recognizable as early as preschool, have the more serious prognosis, characterized by physical aggression and disturbed family and peer relationships. The adolescent onset group tends to be less physically aggressive and more likely to have some positive peer relationships.

Another subtype is characterized by limited prosocial emotions (LPE). Those with LPE appear to lack remorse, guilt, empathy, and concerns about their performance. Characterized by unemotional traits, this subtype includes those with insensitivity to punishment, fearlessness, and planned aggression. This subtype is the most likely to persist into adulthood.

Early Signs of Conduct Disorder

There is evidence that a difficult early temperament may predict the development of CD. Some of these behaviors include emotional hyper-reactivity, irritability, and inflexibility. Other early indicators include below-average intelligence, with especially poor verbal skills. New research suggests that predictors of ADHD and CD can be identified in children of kindergarten age. Poor academic performance and problematic behaviors should be addressed early. Both respond to treatment at a young age. If they co-occur and are not addressed, they are very likely to lead to CD.

Boys with ADHD and CD are twice as likely to have reading difficulties than those with ADHD alone. Both genders engage in delinquent behaviors, but boys’ behaviors tend to be more aggressive than girls.’ Girls are more likely to exhibit lying, truancy, running away, and prostitution. They also tend to engage in more relational aggression, manipulating and verbally abusing others.

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Causes of Conduct Disorder: Genes and Environment

Genetics and environment contribute to the development of both disorders. CD is more likely to develop if a family member has CD or ADHD. Research suggests that harsh and inconsistent discipline coupled with parental neglect or rejection increase the risk of CD. Several studies predict a higher risk in children exposed to chronic trauma, such as parents abusing alcohol or drugs, or struggling with depression. If left untreated, those with ADHD and CD face significant risks of substance abuse, dropping out of school, and trouble with the law. Studies of correctional settings show that more than 40 percent of inmates meet the criteria for ADHD and CD.

Impact of Conduct Disorder on Family Life

Children with ADHD and CD are especially difficult to manage, and parents can’t go it alone. Studies show that many parents — frightened, frustrated, and humiliated by their children’s behavior — tolerate this struggle for an average of two years before seeking help.

Conduct Disorder Interventions and Treatment

The first step is a comprehensive assessment that identifies all risk factors. Interventions should be tailored to the individual based on age, symptoms, temperament, and quality of family relationships. The best solution is a multimodal treatment plan — with active interventions addressing multiple levels of functioning simultaneously. In all cases, psychoeducation should precede any treatment approach, so that all family members understand the disorder, current and potential co-occurring issues, and the long-term outcomes.

Unlike treatment for ADHD, the best interventions for CD are not medication-based. The greatest successes come from a combination of behavioral parent training (BPT) and cognitive behavioral skills training (CBST). These are long-term programs that involve working with a therapist consistently. The psychosocial programs should start as early as possible. Both require serious family commitment but have proved to be quite successful.

Behavioral Parent Training (BPT) can improve parent effectiveness in addressing a child’s challenging behaviors. With a therapist, parents learn to set and enforce appropriate limits, reward desired behaviors, provide consequences for non-compliance, and practice stress reduction techniques. This approach includes contingency management training, to help families create explicit expectations and agreed-upon rewards and consequences. BPT has been shown to improve poor conduct, increase positive parenting skills, and improve parents’ mental health. These sessions are best handled with regular attendance of both parents in the therapist’s office, but there are also programs available on the Internet. While not as effective as in-person training, online programs can be useful if both parents can’t be present for in-office training.

CBST addresses the child’s deficits in social information processing. Focusing on curbing impulsivity and angry responses, the structured sessions teach good interactions with peers, complying with authorities, and handling stress. This training works best one-on-one with a therapist who can role-play, give prompts, and provide immediate feedback. Social competence training is particularly useful for reducing aggressive responses in children ages six to 12.

In family sessions, a psychologist or social worker trained to work with disruptive behavior disorders can provide a check-in for what is being learned in the separate treatments, help to reduce the tension level in the home, allow everyone to be heard in a safe environment, and ultimately bring the family closer together.

Stimulants can help. They don’t target CD behaviors, but they are effective for treating co-occurring ADHD symptoms like impulsivity and irritability, which can worsen CD symptoms. Other medications, like atomoxetine and risperidone, have been shown to have some success in improving agitation and mood.

Prevention programs are an important component. There are early interventions designed to stop the escalation of problems that can be associated with conduct disorder.

Parent support groups offer a window into the lives of others who share similar struggles. This safe context can allow parents to learn from others’ experiences, feel less fearful, and be more hopeful about the future of their family.

The Warning Signs of Conduct Disorder

The DSM-5 diagnostic criteria for CD describe a persistent pattern of behaviors that violate the rights of others and/or societal norms. (In contrast, those with impulsive combined type ADHD alone generally do not intentionally violate the rights of others or social norms.) There are 15 behaviors reflecting four categories of behavior: aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules. A CD diagnosis requires at least three of the 15 behaviors being present in the previous 12 months, and at least one present in the previous six months.

In addition to these core criteria, other characteristics of the disorder are often present. Those with CD tend to have early onset of sexual behavior and substance use. They also tend to perceive others as having hostile intent.

Recent research suggests that CD impairs the ability to correctly read facial expressions, which contributes to misreading others’ intentions. Unable to identify someone’s distress or fear, children with CD may process only emotional intensity. When these children perceive mal-intent in others, they may interpret it as an attack. Those with ADHD and CD often misinterpret facial expressions, while those with ADHD alone generally do not.

Conduct Disorder and ADHD: Next Steps

Ellen B. Littman, Ph.D., has been involved in the field of attention disorders for over 30 years. She is a pioneer in the identification of gender differences in ADHD. Internationally published, she is the co-author of Understanding Girls with ADHD (#CommissionsEarned)

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