With the conduct disordered, it's often difficult to get past the incorrigible behavior and the tumult it creates. But the prevalence of this condition warrants a clearer understanding of other latent, but perhaps more devastating co-morbid conditions, such as mania or depression. To test the hypothesis that dysphoric and non-dysphoric types of conduct disorder (CD) can be distinguished from one another, a research team studied 260 male children between age six and seventeen. One group of 140 children was diagnosed with attention deficit hyperactivity disorder (ADHD), another group was made up of 120 normal controls [J. Affective Disorders 44 (1997) 177-188].

In their examination of patterns of familiality, adversity, and comorbidity, the researchers included cognitive functioning, socioeconomic status, and school dysfunction. Children and siblings were interviewed at baseline and at the four year follow-up point. Parents were assessed at baseline only. Major depression was diagnosed only if the depressive episode was associated with marked impairment. A proband was defined as having a family history of a disorder if a parent or sibling had the disorder at the baseline evaluation.

Of 140 ADHD probands, 38 (27%) also met diagnostic criteria for CD and 30 (23%) for bipolar disorder (BPD) at either baseline or follow-up assessments. Of these, 21 had both CD + BPD. Thus comparisons were made between CD + BPD (21), BPD without CD (9), CD without BPD (17), and ADHD without either BPD or CD. Multiple-domain assessments were used.

The rates of major depression were highest in the two BPD proband subgroups, and multiple anxiety disorders were elevated only in the BPD group.

CD + mania probands had higher familial and personal risk for mood disorders than non-manic CD probands, while other CD probands had a higher personal risk for antisocial personality disorder.

The CD + BPD group had higher rates of familial antisocial and substance use disorders in comparison to the ADHD group. Psychiatric hospitalization among CD probands was almost entirely accounted for by those with comorbid mania (CD + BPD), which is consistent with the notion that CD + BPD probands engage in disorganized aggressive behavior associated with mania. Since many children in psychiatric hospitals with the diagnosis of CD commonly have a profile of severe aggressiveness, it is likely that these children required hospitalizations because of mania not necessarily CD.

The study team also notes that since pharmacotherapy is based on diagnostic hypotheses and no effective treatment for CD exists, these youths may end up incarcerated instead of treated psychiatrically.

As courts attempt to discern which antisocial children warrant alternatives to incarceration, the answer may be: worse (behavior) is better (prognosis)! The study suggests that antisocial youth who frequently fight, lie, steal, or set fires might warrant aggressive medication treatment.