Conduct disorder: A controversial diagnosis with lifelong consequences

Diagnoses are meant to help people access care, but some diagnoses carry far more consequences than others. Conduct disorder is one of them.

Diagnosing someone with conduct disorder can be like placing a lifelong label on them — a label that can shape how educators, clinicians, and institutions interpret behavior long after the diagnosis is made. Studies show that Black, brown, and low-income children are far more likely to be diagnosed with conduct disorder. And the stigma attached to that label can be severe. Even life-altering.

For this episode, we spoke with our brilliant colleague, Dr. Kristin Carothers, a licensed clinical psychologist. She explains what conduct disorder is and why it’s so controversial. And she looks at how race and other biases factor into diagnosis — and what it means to give someone a label that is anything but neutral.

For more on this topic

• Read: The difference between disruptive behavior disorders and ADHD

• Read: More than just a “bad kid”

• Read: Study on racial disparities in ADHD and conduct disorders

• Read: Misdiagnosis of mood disorders in Black teenagers

Episode transcript

Rae Jacobson: Hey y'all, just a note on today's episode. You might notice there's a little more voiceover than usual and a little less of our fabulous guest, Dr. Kristin Carothers. That's because we had some truly wild internet issues during recording, which meant that we lost some of Kristin's amazing tape. We've done our best to add in what was lost via voiceover so we can do justice to the topic. Thanks, and enjoy the episode.

Dr. Kristin Carothers: Because there is such a history of racism in the United States of America, when children who are black or brown present with a concern, they are often labeled as bad and more likely to be jailed for behaviors that would be excused for members of other communities.

Rae: Years ago, in a class on diagnosing mental disorders, one of my grad school professors told us something I never forgot. "The default for diagnosis," he told us, "is and always should be to approach it with thoughtful, thorough caution and an abundance of information."

That said, some diagnoses require an even higher standard, and this is one. The diagnosis he was talking about is conduct disorder. Conduct disorder, as you'll hear more about from someone much more qualified than me, is a serious mental health issue that's diagnosed during childhood or adolescence.

Symptoms include a lack of empathy and remorse and behaviors that are seen as anti-social — remember that word — read: aggressive, reckless, or dangerous. To suggest a diagnosis of conduct disorder, we were warned — and I say suggest because counselors don't diagnose, but we can make recommendations — was akin to putting a lifelong label on someone, one that could too often end up causing serious harm.

Ostensibly, diagnosis should be a neutral tool to help people access understanding, treatment, and support. But nothing lives in a vacuum. Diagnoses are subject to the biases of clinicians who apply them, something that can lead to dire consequences.

It's itched at the back of my mind for years, especially because study after study have shown that black children are far more likely to be diagnosed with conduct disorder, while white children with similar symptoms are more likely to receive a diagnosis of ADHD.

I've also wondered if other clinicians got the same warning I did, and what that says about the vulnerabilities and responsibilities of the people with the power to diagnose, and what it means for people who've been diagnosed with CD. Thankfully, I knew just the person to ask.

I've been lucky enough to know and work with Kristin on and off for a truly unmentionable number of years now. She's an amazing clinician who's made a study of the role that race plays in diagnosis. In short, she's a gem, and she agreed to come on and talk to us about conduct disorder: what it is, why it's controversial, who does and doesn't get diagnosed, and what she wishes clinicians and families knew. And most of all, what it means to give someone a label that is far, far from neutral.

I'm Rae Jacobson, and this is "Hyperfocus". Today on the show, Dr. Kristin Carothers.

(04:27) The definition of conduct disorder and its clinical distinction from oppositional defiant disorder.

Rae: So, can I ask you first, what is conduct disorder?

Kristin: Conduct disorder is basically what we would think of as a precursor to one of the personality disorders known as anti-social personality disorder. So conduct disorder is not something that should be diagnosed lightly, or a diagnosis we throw around. We're looking for some very specific things.

One of the most specific is that a person has presented as a threat to others. They don't have to be provoked. They engage in activities that cause the other person harm for whatever reason. It is not the same as ADHD. It is not the same as a depression. It is a disorder in which people or a person does harm to others.

But the issue, the main issue, is lack of empathy or perspective-taking. When I say empathy, I mean the ability to consider how it feels for another person to be harmed.

Rae: Okay, they can't put themselves in somebody else's position and say, "My actions would make you feel this."

Kristin: Or even if they did put themselves in the other's positions, they have what's called a callous or unemotional trait. That callous or unemotional trait means that they don't feel feelings of pain, sadness, grief with the same intensity that other people would experience when asked to take a perspective. So what they want is more important.

Rae: Conduct disorder lives on the extreme end of a kind of spectrum of what are called disruptive behavioral disorders, or DBDs. In this same family is another, more common disorder called oppositional defiant disorder, or ODD. Kristin explains.

Kristin: So with an oppositional defiant disorder, most often you find that ODD can be present in one context and not be present in another. So a child may present as defiant in the household setting but present as, like, on task in the classroom setting.

And so what we want to make sure of when we're distinguishing between ODD and a conduct disorder is that ODD can be something that is really contextual. So it could be that within the context of having different personality characteristics or mismatch between parents and kids, and also within the context of having maybe parents who engage in some parenting practices that aren't a good fit for their kid, that child may present with defiance and disruptive behavior. So refusing to comply with requests, acting out in one setting.

With a conduct disorder, you're going to see that those behaviors go across settings. So if they are aggressive or threatening or menacing to people or struggle with that empathy or perspective-taking, that happens at home, that happens at school, that happens in social situations. And with a kid with a conduct disorder, you are almost worried for that child to be left alone because they could do harm to someone else.

Or they have done harm to someone else — a person, an animal, or they've stolen or done something of that nature. And so when we look at an ODD, we're really looking at oppositionality. Meaning if a teacher says left, they say right, consistently. Defiance that is consistently your rule-breaking behavior. And I think what is difficult for people is trying to figure out the function of the rule-breaking behavior.

And that's where I think oppositional defiant disorder and conduct disorder can kind of get intertwined in certain communities where we want to be really careful about applying a diagnosis of an oppositional defiant disorder or a conduct disorder when we are not taking into account uncontrollable stress, exposure to violence, and other things that might make it such that a child or an adolescent engages in some rule-breaking behaviors for survival purposes.

Rae: Though ODD is less severe than conduct disorder, it carries its own share of challenges for diagnosticians. Conduct disorder and, to a lesser degree, other behavioral disorders like ODD are heavily stigmatized, and it's easy to see why.

These behaviors Kristin is talking about can sound pretty frightening. Defiance, acting out, lack of empathy, violent behavior, taking things that don't belong to you — all things we associate with another, less clinical word: criminal.

And we know from research that black, brown, and low-income kids are far more likely to be diagnosed with these disorders than white children. And on top of that, we know that a conduct disorder diagnosis puts kids at greater risk for interaction with law enforcement and much greater risk for incarceration.

The problem with this is that a lot of these diagnoses come down to how people are perceived. And that introduces bias — conscious or unconscious — on the part of the people who are interacting with the kids. Behavior that's seen as defiant or oppositional in a black child might be viewed quite differently in a white child.

(10:12) "Adultification" and its impact on the sentencing and treatment of children of color.

Rae: You, as ever, are amazing because you have just segued into why I asked you here to talk about conduct disorder. One of the reasons I wanted to bring you here is because when I was in grad school for counseling, conduct disorder came up when we were talking about diagnosis. We didn't diagnose as counselors, but we could make recommendations.

And one of the things — and this was in Louisiana — that they really hammered into our heads was conduct disorder and ODD, to a lesser degree, are not neutral. If you think that's happening, you need to check yourself considerably because if you even recommend that a child get a diagnosis like that, you are labeling them for life.

And one of the things that they brought up — and again, I bring up Louisiana because this is a very prominent thing there — the school-to-prison pipeline there is very slick. The wheels are greased, and it is something that is a serious concern for people who are diagnosing, families, anyone who interacts with the school system. This is a really serious thing.

So when I think about conduct disorder and ODD, I think about the idea that diagnosis as a whole is non-neutral, but that these diagnoses are significantly less neutral. Could you tell me a little bit about your experience with that and why this is?

Kristin: I like the way that you said once the diagnoses are made, the pathway from the school to the prison pipeline becomes like really slick. So things move really quickly. In my training, I was basically taught much of the same thing as you.

And my training predominantly occurred with children and adolescents who were low-income, urban and black, and children and adolescents who were low-income, urban and Latino — Dominican, Mexican-American, etc. And what we found is that because there is such a history of racism in the United States of America, when children who are black or brown present with a concern, they are often labeled as bad rather than looking at what types of contextual factors are in place that might perpetuate certain behaviors.

And so when we are trying to decrease stigma, when we're trying to really give people help, we want to take into account the fact that there is a structure that exists that is racist that will perpetuate myths about functioning. And then people won't get real help because of stigma associated with seeking help and because of the fear that if they do seek help, they'll be labeled and more likely to be jailed for behaviors that would be excused for members of other communities.

Rae: I've seen multiple studies, but a recent one, specifically this one, was about black girls versus white girls in terms of black girls being significantly more likely to be diagnosed with conduct disorder instead of ADHD, and white girls being significantly more likely to receive a diagnosis of ADHD. Does that bear out in what you've seen around this type of diagnosis?

Kristin: So what I've seen with the diagnosis and, in general, in terms of how schools manage behavioral problems with black girls versus white girls is that black girls are going to be more likely to be suspended for similar behaviors that might be excused away for white girls.

What I've also seen is the adultification of black girls and black boys, and that's another cultural phenomenon that is unique to the United States of America, which is another reason we want to make sure that we are not applying the label when a better descriptor or better understanding of the function of a behavior should be applied.

Rae: Can you help me understand adultification? Can you spell that out for me?

Kristin: Sure. Adultification just means that children of color are more likely to be seen as much older than they actually are by people who are not members of the same ethnic group. And that is likely because there have been myths perpetuated in society that adults of that group are dangerous, and that children who are members of that group are bad and also dangerous.

And so what happens is a girl who is 12 and who might be physically developed or not physically developed is seen as a 16 or 17-year-old and then treated that way. That is a real phenomenon that occurs. For boys of color, especially black male children, once they pass puberty or once they hit puberty, they are no longer viewed as cute by people who are not of the same ethnic group and they are likely to be treated as such. And this can be documented anecdotally and in the research literature.

Rae: So children of color are not treated like children and then they're held to a standard of adulthood. So a kid who's maybe acting out in the way a 10-year-old would act out is treated as if they're acting out as 17.

Kristin: And then they're punished and labeled as if they were 17. So even if you look at — I happen to do forensic psychology work as well. So even if you look at children who are involved in the justice system, black children are going to be more likely to be referred for what we call a transfer evaluation — for crime to be considered a felony and them to be tried as an adult than white children who might commit the same crime.

So as forensic psychologists, then that gives us another level of responsibility in understanding functioning context and advocating for children of color since we know that the judicial system may be more likely to see them as adults or to want to see them as adults and to treat them harshly as a result.

Rae: How old someone is when they're diagnosed with something matters. Take, for example, personality disorders. These, Kristin explains, are only diagnosed in adulthood, largely because during childhood and adolescence, kids' personalities are still in flux: developing, changing, growing.

The idea, the hope being that if a child is struggling, with the right help, trajectories can change. That's why conduct disorder is diagnosed in childhood, which is to say before the age of 18. Children who still meet criteria for CD at 18 are sometimes — sometimes — given a new diagnosis, one listeners might be more familiar with: anti-social personality disorder, or ASPD. This is what people are often referring to when they use the term "sociopath".

But, and I want to be very clear here, this is why I harp on "sometimes". This isn't a given. About 40% to 50% of kids who met criteria for a conduct disorder diagnosis as minors will go on to have a diagnosis of ASPD as adults. That means half, or sometimes more than half, do not.

This is one of the reasons conduct disorder is such a serious diagnosis. Black children are simultaneously more likely to be adultified and to be diagnosed with CD. Too often they're not seen as children whose personalities are still in flux, but as adults, with all of the weight that that diagnosis carries during adulthood.

And so if, say, a kid comes in contact with the justice system and the person who's evaluating them looks and they see a CD diagnosis, what does that tell them about that child? What happens after that?

Kristin: Well, what should happen is that they should be curious about why such a diagnosis has been given. And so we want to make sure that we are doing sound evaluation, evaluation that is evidence-based, evaluation that incorporates not just the child, but the child's parents, the child's school, the child's community to get a full picture of what might be happening. When we diagnose children, when we evaluate children, we want multiple reporters to provide us with information so that we can paint a full picture.

(16:18) Environmental factors and resource disparities that clinicians must consider during the evaluation process.

Rae: That full picture, as Kristin says, is an essential part of a good diagnosis. It's what helps clinicians guard against internal bias, helps them see the person they're diagnosing as a whole person with all the things that make that true: their history, their relationships, who they are in different settings, what might be happening in their life. A person, not just a set of behaviors.

But in an inequitable world, the level of care that should be the basic standard for everyone is often a luxury only available in some areas and some income brackets. This is something Kristin has seen firsthand over her long career.

During her early training at DePaul University, she worked at a community health center in Chicago that served kids from the surrounding public housing projects, including Cabrini-Green and Marshall Field Gardens, where resources were scarce and need was high. She's also worked at places like the Child Mind Institute and Columbia University, where patients had access to a wealth of resources and a high level of care. The differences, not just in care but in standard of diagnosis, were stark.

Kristin: These children were living below the poverty line, the schools all were probably 99% of the kids received free or reduced lunch. There wasn't lots of access to mental health care.

In addition, most of the children had been exposed disproportionately to uncontrollable stress in the forms of violence. And that's something that comes along with poverty, right? And so these are kids who are living in poverty where there are scarce resources, where the only time they really can access mental health care is if the school is able to provide it.

And so DePaul partnered with schools to provide that mental health care. We only had one psychiatrist on staff, and we were providing psychiatric care for three schools in that area.

And so what you find is if the kids are really dependent on us or dependent on community providers who are grant-funded, it's going to be hard to get them the same level of care that you would be able to get at a Child Mind Institute where we've got multiple psychiatrists, we've got psychologists who are all engaging in evidence-based care, we've got parents who are more affluent and who are able to access lots of different resources because they have money.

And so what you would see is that kids get more chances when their parents are more affluent. Their parents can afford — right, it doesn't mean that those kids aren't struggling who are affluent, they are still struggling, yes. But their parents are able to access a different level of care.

And so when we look at diagnosis, what you are hoping is that kids are interfacing with providers who are not so taxed that they can do a full, solid evaluation. What you are hoping on the flip side is that you aren't getting providers who are just giving parents what they want because they can pay for it. So there are problems, right? However, children who are poor are going to be at greater risk for being misdiagnosed, mislabeled, and mistreated.

Rae: And to your earlier point, it sounds like there's also a layer of you're working with kids in poverty, you're also working with a predominantly black and Latino population. We know racism is absolutely present and that comes into diagnosis as well.

Kristin: And there's no diagnosis for racism, right? It's not a part of the DSM. We have what's called a cultural formulation that happens to be at the back of the manual. And what we ask clinicians to do as part of the cultural formulation and the contextual formulation is to be aware of the cultural beliefs, religious beliefs, the traumas that a family could have experienced, how context impacts them.

So if you're living in a public housing community at that time that was about to be demolished and replaced with million-dollar townhomes and million-dollar condo buildings, and you're going to have to move from the place where your family for generations has lived and dispersed across a city where you've got across gang boundaries and you've also got to learn how to live in a home when you've only lived in an apartment complex, right?

And I say this as a person whose family came out of public housing in Chicago. I also worked public housing in Jamaica, Queens, and Queensbridge housing projects in Flushing. I've also worked in very affluent settings once I got to New York. But even when I was working in Washington Heights, the population is predominantly immigrant and a lot of the parents that I worked with did not speak English.

And so the barriers to trying to provide for your child who presents with mental health difficulties or emotional difficulties while being an immigrant, while not speaking English as a first language, while trying to make ends meet — there are so many stressors that are present that are not accounted for.

(18:23) The complexities of diagnosing and treating conduct disorder in diverse populations.

Rae: So what does all this mean for a troubled diagnosis? It's tempting to say that this is a label so fraught that we should reconsider using it at all. But that's not quite the answer either. Because conduct disorder is real, and it is extremely serious. And there's evidence that suggests under-diagnosis or misdiagnosis can be catastrophic for people with CD. That's because with accurate diagnosis, there are treatments that can help.

Kristin: We've got to be careful either way. With that being said, I was a forensic psychologist for the Department of Behavioral Health and Developmental Disabilities for the State of Georgia. There were adolescents I saw who definitely met criteria, but that was rare.

Rae: Well, this is a question I have for you is that while I was doing research for this episode, I found multiple articles — scholarly journal articles — saying that there's a concern that sometimes people are so afraid to diagnose CD that it's under-diagnosed and kids don't get help or support that they would get if they had an accurate diagnosis. Which kind of led me to a question that I don't know the answer to, which is: what do you do for someone with CD? How can you help somebody? If you have an accurate diagnosis, what is the treatment?

Kristin: So the treatment is really a behavioral treatment. It's like highly structured. First of all, kids who are diagnosed with a conduct disorder typically are going to have to have great deals of supervision and the intervention is an intervention that is behavioral.

What the research shows is that response cost interventions — and what response cost means is that you earn for on-task behavior, you lose for off-task behavior. It's the predominant interventions, right? But there's a greater response to earning than there is to losing.

And so as long as the behavioral intervention is one in which the kid can earn what they want at increasing levels to try to shape into appropriate behavior, that's the piece of the intervention that works. But they also have to be consistent consequences.

And when we say consequences, consequences can be positive-negative. And when I say positive-negative, I mean math — adding something to the situation or subtracting something that was previously there to increase or decrease behavior. So it's got to be consistent.

If there was a stealing infraction, then you lose this for this finite period of time. If you did not steal and you followed the direction, then you earn this. But very highly structured, very consistent, and very behavioral.

(22:13) Guidance for clinicians navigating the high stakes of diagnosing conduct disorder.

Rae: So if conduct disorder is a diagnosis that we need, because some kids have it, but it's also as far as I can tell almost a nuclear diagnosis for a lot of children — predominantly black and brown children — what do we do with something like that? What do you as a clinician wish people knew about that so that they could be more accurate, be more helpful? I don't know, where do we go from here?

Kristin: I think clinicians should know that there is no pressure for them to make the diagnosis and they should consult, consult, consult with experts. Most likely those experts will be people who are forensic psychologists who have experience working with children and adolescents who present with these types of behaviors, right?

And so if you're not an oncology expert, you don't go around diagnosing a cancer because you are a regular medical doctor. You may see the labs and see that there are some elevations in PSAs or whatever the elevated number is, right? And then you say to your patient, "You need to go for a follow-up."

And so what clinicians need to know, and parents if they are trying to diagnose their children, is that you need to seek expert consultation. This is not a diagnosis that should be made lightly or that clinicians should often make without the absence of other information. If you're not an expert, seek support.

Rae: I know a million clinicians, so do you. We're humans and we have biases, and they come with us into the clinical room. They're present when we think about diagnosis. How do you keep those out of your work? And how do you hope that other clinicians are working to do that? Because, you know, to all the points we've made, this is something where we are not neutral. We are acting and we're acting as human beings with all the complexities that that entails.

Kristin: I think the first step is like awareness that as clinicians, we have bias. We bring our biases to the table because we also bring our values to the table. We are not perfect, we're not expected to be perfect, but it is important that we're aware. And if we lack awareness or insight, then we could do more harm. And so our goal as clinicians is always to do no harm. We want people to leave us better than they came.

Rae: That's all for this episode. Thank you to Kristin, and thank you for listening. As you can tell, this is a topic I really care about and would like to cover more. If you have a conduct disorder story, whether you were diagnosed as a child or you diagnose, we want to hear from you. And if you have questions or thoughts about today's episode, let us know. You can leave a comment on YouTube or write to us at hyperfocus@understood.org. See you next time.

"Hyperfocus" is made by me, Rae Jacobson, and Cody Nelson.

Our music comes from Blue Dot Sessions. Our research correspondent is Dr. KJ Wynne. Video is produced by Calvin Knie and edited by Alyssa Shea.

Briana Berry is our production director. Neil Drumming is our editorial director. Production support provided by Andrew Rector.

If you have any questions for us or ideas for future episodes, write me an email or send a voice memo to hyperfocus@understood.org. 

This show is brought to you by Understood.org. Our executive directors are Laura Key, Scott Cocchiere, and Jordan Davidson.

Understood is a nonprofit organization dedicated to empowering people with learning and thinking differences, like ADHD and dyslexia. If you want to help us continue this work, donate at understood.org/give.