The recent NICE guidance on conduct disorders (CDs)1 places paediatricians centre stage in the assessment process. With behavioural disorders contributing to 25–30% of some paediatricians’ caseloads,2 it is very gratifying to see our role appropriately recognised. This is not always the case. Both here and abroad, paediatricians complain that, despite being an integral part of child mental health service provision, at a national level we often seem invisible.3

Now, for a question: which clinical conditions are your most difficult? Paediatricians, probably universally, most often cite CDs.4 A UK survey of trainees’ child mental health training requirements, conducted in 2006, sent back a very strong message of feeling under-prepared, and over 90% of respondents said they needed more training, particularly in behavioural disorders (M Davie, personal communication), a perception also shared by recently appointed consultants.5

A resolution to this problem will hopefully flow from two major College initiatives: the “Child in Mind” educational modules for the first years of specialist training, and the appointment of a new specialist consultant in child mental health.

So, in this context how should paediatricians work with CDs?

WHAT IS CONDUCT DISORDER?

CD, the most common problem referred to child and adolescent mental health services (CAMHS),6 is defined by ICD-10 and DSM-IV criteria as a persistent pattern of behaviour in which the basic rights of others, or major societal rules, are violated. CD, at the extreme end of the spectrum, is one of a triad of closely related and overlapping patterns of difficult and challenging behaviour known as disruptive behaviour disorders (DBD) which includes attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). ODD is a milder pattern of negativity, defiance …