Journal of Biosciences and Medicines, 2018, 6, 57-61

http://www.scirp.org/journal/jbm
ISSN Online: 2327-509X
ISSN Print: 2327-5081

Aggression and Conduct Disorder in Young

Children. A Case Report

Hadia Crider, Kunal Malhotra, Garima Singh

University of Missouri Hospital and Clinics, Columbia, USA

How to cite this paper: Crider, H., Mal- Abstract

hotra, K. and Singh, G. (2018) Aggression
and Conduct Disorder in Young Children. Childhood Onset Conduct Disorder [CD] is a condition characterized by at
A Case Report. Journal of Biosciences and least one symptom of conduct disorder (based on Diagnostic and Statistical
Medicines, 6, 57-61. Manual of Mental Disorders criteria—Fifth Edition) prior to 10 years of age.
https://doi.org/10.4236/jbm.2018.62005
Children affected exhibit disruptive behaviors, usually negative, hostile, and
Received: January 9, 2018 defiant behavior similar to Oppositional Defiant Disorder [ODD]. As the
Accepted: February 24, 2018 child gets older they begin to display more characteristic of Conduct Disorder
Published: February 27, 2018
(lying, fighting, and stealing, vindictive behavior). These children are also
Copyright © 2018 by authors and
likely to have comorbidities including Attention Deficit Hyperactivity Dis-
Scientific Research Publishing Inc. order (ADHD), learning disabilities, poor academic achievement, and sub-
This work is licensed under the Creative stance abuse. Distinguishing early between symptoms of Conduct Disorder
Commons Attribution International
versus other differential diagnoses is essential in effective treatment. Early in-
License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
tervention with these children leads to a better prognosis and likelihood of
Open Access functioning in society. This case illustrates the difficulty of diagnosing a
young child with Childhood Onset Conduct Disorder.

Keywords
CD, Conduct Disorder, Aggression, Young Children

1. Introduction
This case illustrates the complexity of this diagnosis in a young child. He is a vic-
tim of neglect and presents with suggestive symptoms of Childhood Onset
Conduct Disorder. He has no prior psychiatric history. He was diagnosed with
ADHD and Disinhibited Social Engagement Disorder after initial psychiatric as-
sessment. His medical history is unremarkable. Patient was born vaginally at 40
weeks with no complications at birth; however he was exposed to methamphe-
tamine in utero. His developmental milestones were significantly delayed in
communication, motor, and social skills. He lived with biological mother from

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H. Crider et al.

birth until age 2. During this time he suffered from neglect and malnutrition.
His biological mother was not living in a stable home and would stay with
friends. She was using illicit substances during this time period. Children’s ser-
vices removed him from mother’s custody and he was placed with biological fa-
ther and stepmother. He does not have current contact with biological mother.

2. Demography
Patient is a 5 year old male from Missouri. He lives with father, stepmother,
2-year old brother, and 13 year old cousin. He is in Kindergarten.

3. Mode of Referral
He was seen for an initial psychiatric evaluation at the Outpatient Clinic for
Autism Spectrum Disorder and Developmental Disorder and then a month later
was admitted at an inpatient psychiatric facility after family brought him to the
emergency room for safety concerns.

4. Case Presentation
A 5 year old male with no past psychiatric history was seen for the first time at
the Outpatient Clinic for Autism Disorder and Developmental Disorder for im-
pulsive and violent behavior since age 2. History was provided mostly from par-
ents (father and stepmother) during the initial assessment. According to his
parents he was having issues with impulse control, short attention span, and
hyperactivity. His behavioral issues were extreme and difficult to redirect. He
would become upset with little or no triggers and then proceed to kick, scream,
urinate, and defecate in the living room and smear feces on the wall. He would
attempt to hurt his 9 month old baby brother multiple times. Parents were re-
ported to Child Protective Services because he gave baby brother a black eye by
hitting him with a sock filled with nuts and bolts. He was violent towards ani-
mals and snapped the necks of multiple animals (9 cats, 4 rabbits, 1 turkey, 3
baby hawks, multiple dogs and pigs) and per parents was not remorseful about
his actions. During interview he admitted to hitting a pig in the eye with a ham-
mer because he thought it was funny. His behavioral problems and outbursts
were also occurring at school. He starts fights with the other kids by kicking,
biting, and punching them. He lies to get out of trouble. He steals things from
the other kids at school. He plays aggressively with toys and breaks them, throws
them, and stomps on them. He is sensitive to loud noises. He has difficulty using
a fork and spoon. He self-reported his mood to be happy. He denies any mania
symptoms. He denies any issues with anxiety. He denies any psychotic symp-
toms. He reports having inattentive and hyperactive symptoms of ADHD which
was attested by parents and teachers report. After his initial appointment he was
referred for neuropsychological testing to screen for Autism Spectrum Disorder.
He was started on medications, Guanfacine 0.5 mg qam, qnoon to manage im-
pulsive behaviors. He was given a diagnosis of Disinhibited Social Engagement

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 H. Crider et al.

Disorder, ADHD, and r/o Conduct Disorder. A month later he was admitted to
an inpatient psychiatric hospital after family brought him to the emergency
room due to him making homicidal threats towards family members. He
grabbed a knife and held it up to his 13 year old cousin, threatening to kill her
because she wouldn’t let him watch TV. Patient also continued to see aggressive
behaviors towards peers at school and animals. At home stepmother increased
his dosage of Guanfacine to 1 mg BID without any improvement in behaviors.
Patient remained on the inpatient unit for a week. During this time he was ta-
pered off Guanfacine and started on Amphetamine 2.5 qam for ADHD symp-
toms and Clonidine 0.05 mg qhs to help with sleep. Medications were later ti-
trated to Amphetamine 5 mg in morning and Clonidine 0.1 mg at bedtime.
While he was on the inpatient unit it was determined that his violent tendencies
were likely due to a lack of supervision. This determination was made from col-
lateral information provided by his social worker. The diagnosis of r/o conduct
disorder was removed from his diagnosis list and intensive home and commu-
nity services were initiated. The neuropsychological testing showed he did not
meet criteria for Autism Spectrum Disorder. He was continued on medications
for ADHD and impulsivity (Amphetamine 5 mg in morning and clonidine 0.1
mg at bedtime) and is participating in intensive family intervention services.

5. Discussion
It is a challenge when diagnosing a young child with Childhood Onset Conduct
Disorder. Children find it difficult to verbalize their feelings. Their symptoms
can have different meanings based on their developmental levels. In order to di-
agnose Childhood Onset Conduct Disorder individuals show at least one symp-
tom characteristic of conduct disorder prior to 10 years of age [1]. In Childhood
Onset Conduct Disorder, a combination of biological and psychosocial factors
appears to contribute to the disorder. Children with Childhood Onset Conduct
Disorder tend to be mostly male. The incidence of CD is not related to socioe-
conomic class or ethnic group. However research has shown children with
Childhood Onset Conduct Disorder do have the following social factors: pover-
ty, lower socioeconomic status, poor education, increased criminality in parents,
substance use in parents, decreased community support, poor school achieve-
ment or poor family structure [2] [3]. These children tend to be more aggressive
than the adolescent-onset youth. By age 18, the majority of youth with Child-
hood Onset Conduct Disorder meets the criteria for antisocial personality dis-
orders and often end up incarcerated. The prevalence of Conduct Disorder is es-
timated between 2% and 8% of the general child and adolescent population. The
prevalence of Childhood Onset Conduct Disorder is 3% to 5% of youth with
Conduct Disorder [4]. These children display disruptive behaviors early in
childhood, usually as negative, hostile, and defiant behavior similar to opposi-
tional defiant disorder. As the child grows, there is an escalation to behaviors
more characteristic of Conduct Disorder (lying, fighting, and stealing, vindictive

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H. Crider et al.

behavior). These children are also likely to have ADHD, learning disabilities,
and poor academic achievement. A consistent finding is that children with
ADHD are likely to have persistent conduct problems that extend into adult-
hood [2]. The association between ADHD and Conduct Disorder is especially
strong for boys, although girls show a higher risk than boys to develop Conduct
Disorder if they have ADHD [2] [5]. The addition of substance abuse to ADHD
and Conduct Disorder is predictive of violent behavior for boys. Early treatment
for ADHD, ODD and substance abuse is important in the treatment of Conduct
Disorder. Children with Conduct Disorder also may show other forms of neu-
ropsychiatric and neurobiological differences, such as low CSF serotonin levels
and abnormal dopamine B-hydroxylase (DBH), reduction of grey matter in the
amygdala which might indicate a reduction in fear conditioning [6]. As these
children grow they have a higher risk of substance abuse, erratic employment
and physical abuse of their partners and children. There is also a high rate of
symptom overlap of Conduct Disorder with other differential psychiatric diag-
noses. Children can have irritable and impulsive/dangerous behaviors associated
with ADHD, Anxiety, depression, substance use, learning disorders, mania, fetal
alcohol syndrome, abuse victims, Reactive Attachment Disorder [RAD] [2].
Some of these disorders can also be comorbid (ADHD, depression, anxiety, sub-
stance use, and learning disorder) which makes it difficult to make an accurate
diagnosis of Childhood Onset Conduct Disorder. Childhood Onset Conduct
Disorder requires early intervention and long term follow-up. These children
benefit from multiple sessions of therapy for longer periods of time. There is no
pharmacological intervention to treat Conduct Disorder however comorbid is-
sues need to be addressed (anxiety, depression, ADHD, substance use) [4].
Conduct Disorder children benefit from Cognitive Behavioral Therapy [CBT]
(particularly problem solving skills training (PSST), family intervention (parent
training for consistent behavior interventions), school intervention (appropriate
academic interventions and social engagement with peers), and working with a
juvenile officer. Patients may also benefit from long term residential treatment
facilities if behaviors continue to be extreme [4]. Antipsychotics are used to
manage aggressive behaviors [7].

6. Conclusion
Childhood Onset Conduct Disorder can be difficult to diagnose due to comor-
bidities, symptoms presentation as well biopsychosocial factors as in the case
presented. It was determined that his behaviors were due to a lack of supervision
in the home versus a diagnosis of Childhood Onset Conduct Disorder. The early
recognition and interventional treatment of Childhood Onset Conduct Disorder
can prevent legal issues and future incarceration. Treatment includes treating
comorbidities, CBT, Family and school intervention/psychoeducation modifies
behaviors. Antipsychotics may be used to manage aggressive behaviors. In the
patient’s case he is being treated for ADHD. His parents are using behavioral

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 H. Crider et al.

techniques with him to help modify his behaviors. Since implementing these
techniques and using ADHD medication his behavior continues to improve. He
is not as impulsive as previously and will think through his decisions. He is re-
cognizing his behavior has consequences and will be punished if he doesn’t fol-
low the rules set by father and stepmother. He will ask permission to do things
instead of just doing what he wants. He is not running away from home or
school. He has not had any additional instances of animal cruelty. His current
management (treating ADHD, CBT, and family intervention) has improved his
prognosis.

References
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