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Stem
A 9-year-old boy is brought to clinic by his mother. Over the past year he has been bullying younger children at school, initiating physical fights, and was caught setting fire to a garden shed. He stole a bicycle from a neighbour and lied about it. His mother reports he shows no guilt or empathy and seems unconcerned when punished. He stays out until midnight despite her rules. His father is in prison and his mother has depression. He is failing at school and has been excluded twice. There is no history of day-time urinary symptoms.
Questions
a) What is the most likely diagnosis, and list the DSM-5 diagnostic category of symptoms he demonstrates? (2 marks)
Conduct disorder (CD), childhood-onset type (at least one symptom before age 10), with the callous-unemotional traits specifier (lack of guilt/empathy). The symptom categories are: aggression to people (bullying, fighting), destruction of property (fire-setting), deceit/theft (stealing the bicycle, lying), and serious violation of rules (staying out late despite parental prohibition).
b) State the DSM-5 duration and threshold criteria for this diagnosis. (2 marks)
At least 3 of 15 criteria present in the past 12 months, with at least 1 in the past 6 months, causing clinically significant impairment in social, academic or occupational functioning. Onset specifies childhood-onset (at least one symptom before age 10) versus adolescent-onset.
c) Outline the stepwise management, citing first-line evidence-based interventions and any medication role. (4 marks)
- Multi-informant assessment — interview child, mother, obtain school report; use the SDQ; assess for comorbid ADHD, depression, learning disability; full safeguarding assessment.
- First-line: parent training programme — e.g. Incredible Years, Triple P, or Parent-Child Interaction Therapy (PCIT) per NICE CG158. Group-based for moderate severity; individual for complex families.
- For severe CD, add Multisystemic Therapy (MST) — intensive home/community intervention addressing family, peer, school and neighbourhood.
- Child-focused adjuncts — problem-solving skills training, CBT-based anger management; school liaison and classroom management.
- Medication is a last resort: no drug treats the core disorder. Low-dose risperidone (atypical antipsychotic) short-term, under specialist supervision with monitoring (weight, prolactin, metabolic), for severe aggression refractory to psychosocial intervention. Methylphenidate only if comorbid ADHD.
- Address parental depression, social determinants, and safeguarding concerns.
d) What is his prognosis and what childhood factor most worsens it? (2 marks)
Childhood-onset CD with callous-unemotional traits carries the worst prognosis — about 50 percent progress to antisocial personality disorder in adulthood, with high rates of criminality, substance misuse and school dropout. Good prognostic factors: higher IQ, prosocial skills, supportive family, school engagement, early multimodal intervention.