Changes

April 2023 — reviewed. A literature search was conducted in March 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. Definitions have been updated in line with the 11th revision of the World Health Organization's International Classification of Diseases (ICD-11). The topic has undergone minor restructuring, and additional recommendations regarding assessment in primary care have been added. No major changes to the recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Identify possible conduct disorders in children and young people.
• Ensure appropriate referral to specialist teams for diagnosis and initiation of treatment, where appropriate.

Outcome measures

Audit criteria

No audit criteria relevant to primary care were found during the review of this topic.

QOF indicators

QIPP - Options for local implementation

NICE quality standards

NICE quality standards that are relevant to primary care include:

Statement 2. Children and young people with a suspected conduct disorder and any significant complicating factors have a comprehensive assessment, including an assessment of the child or young person's parents or carers.

Statement 4. Parents or carers of children with a conduct disorder aged 3 to 11 years are offered a referral for group or individual parent or carer training programmes.

Statement 5. Children and young people aged 11 to 17 years who have a conduct disorder are offered a referral for multimodal interventions, with the involvement of their parents or carers.

[NICE, 2014]

What is it?

• The term 'conduct disorders' describes persisting disruptive or dissocial behaviour.
• The National Institute for Health and Care Excellence (NICE) defines conduct disorders as being characterised by repetitive and persistent patterns of antisocial, aggressive, or defiant behaviour that amounts to significant and persistent violations of age-appropriate social expectations. This definition is based on the World Health Organization's ICD-10 (International Classification of Diseases, Revision 10) classification of mental and behavioural disorders.
• The updated ICD-11 replaces the term 'conduct disorders' with 'disruptive behaviour or dissocial disorders'. Clinical features shared by all behaviour or dissocial disorders, as defined by ICD-11, are persistent behaviour problems across multiple settings that range from markedly and persistently defiant, disobedient, provocative, or spiteful to those that persistently violate the basic rights of others or major age-appropriate societal norms, rules, or laws.
  • Disruptive behaviour or dissocial disorders include the following types:
    • Oppositional defiant disorder.
    • Conduct-dissocial disorder.
    • Other disruptive behaviour or dissocial disorders (that share the common clinical features but do not fulfil the diagnostic requirements of the disorders above.)
• Oppositional defiant disorder involves interpersonal conflict with authority figures and difficulty getting along with others, whereas conduct-dissocial disorder involves more severe and dissocial behaviour that violates the basic rights of others or social and cultural norms (for example aggression towards people and animals, theft, destruction of property, and deceitfulness.) The two diagnoses may co-exist and, in some cases, oppositional defiant disorder may be a precursor to conduct-dissocial disorder.

[NICE, 2017a; WHO, 2023]

What risk factors are associated with conduct disorders?

The cause of conduct disorders is unknown, but evidence suggests it involves the interplay of genetic and environmental factors.

• Risk factors that increase the likelihood of conduct disorders include:
  • Individual characteristics
    • Male sex. Boys are 1.4 to 2.5 times more likely than girls to develop conduct disorders.
    • Children with recognised special educational needs. A 2017 NHS Digital survey found that nearly one in four children with a recognised educational need had a behavioural disorder, compared with one in thirty children who did not have a special educational need (23.1% vs 3.3%).
    • Coexisting conditions and mental health problems — these are observed in 46% of boys and 36% of girls with a conduct disorder. Coexistence with attention deficit hyperactivity disorder (ADHD) is particularly prevalent, being observed in more than 40% of some groups of children and young people with conduct disorders.
  • Risks within the family
    • Having a parent or sibling with a conduct disorder.
    • Having parents with poor mental health.
    • Physical or sexual abuse.
    • Frequent changes in caregivers, or experience of early institutional living.
    • Being rejected by parents or experiencing permissive, neglectful, harsh, or inconsistent parenting.
    • Exposure to marital conflict and/or domestic violence.
    • Family poverty/deprivation.
    • Maternal smoking during pregnancy.
  • Risks outside the family
    • Being bullied.
    • Physical or sexual abuse.
    • Involvement with other difficult young people.
    • Substance misuse.

 [APA, 2013; NICE, 2017a; RCPsych, 2015; NHS Digital, 2018; Fairchild, 2019; WHO, 2023]

How common is it?

• Conduct disorders and associated antisocial behaviour were previously considered the most common mental and behavioural problems in children and young people [NICE, 2017a]. More recent data suggests, however, that emotional disorders and behavioural disorders have a similar prevalence  [NHS Digital, 2018].
• In 2017, an NHS Digital survey found 4.6% of 5 to 19 year olds in England had a behavioural or conduct disorder [NHS Digital, 2018]. Rates were higher in boys (5.8%) than in girls (3.4%). Oppositional defiant disorder was the most common type, present in 2.9% of children. Rates varied by ethnicity, being highest in white British children (5.7%) and lowest in those who were Black/Black British (0.7%) or Asian/Asian British (0.8%). Children living in the lowest income households were three times more likely than the most affluent children to have a behavioural disorder.
• The 2017 survey showed prevalence rates peak in 11 to 16 year olds, although data for those aged 17-19 may be less accurate [NHS Digital, 2018]. Onset is, however, considered rare after the age of 16 [WHO, 2023]. Initial symptoms of oppositional defiant disorder typically appear in children of preschool age [WHO, 2023].
• A large UK observational study performed by the Office of National Statistics between 1999 and 2004 found that nearly 40% of children who are being 'looked after' (for example in foster care or children's homes), or who have been abused, or who are on the child protection or safeguarding register, met the diagnostic criteria for conduct disorders [ONS, 2005; NICE, 2017a].

What is the prognosis?

The prognosis for those with an established diagnosis of disruptive behaviour or dissocial disorders is variable. 

• Adolescent onset (older than 10 years of age) is associated with a better prognosis than early onset (younger than 10 years of age):
  • Approximately 85% of people with adolescent-onset will have ceased any antisocial behaviour by their early 20s.
  • Approximately half of all children with an early onset condition have serious problems that persist into adulthood, for example:
    • Committing violent and non-violent crimes.
    • Psychiatric problems such as antisocial personality disorder (which develops in approximately 50% of cases), alcohol and drug abuse, anxiety, depression, self-harm, and risk of suicide. Children who have ADHD in addition to conduct disorders are particularly at risk of developing these problems.
    • Poorer school performance, including below-average examination results and higher rates of truancy and early school leaving.
    • Unemployment, with any jobs being held for a shorter time, and jobs being more likely to be of low income.
    • Relationship problems, having few (if any) significant friends, low involvement with relatives, and a tendency towards short-lived, violent, cohabiting relationships with partners who often also exhibit antisocial behaviours.
• A worse prognosis is associated with:
  • Early expression of callous, unemotional behavioural traits.
  • Behaviours that are severe, frequent, and varied.
  • Hyperactivity and attention problems.
  • Lower intelligence.
  • Parental criminality or alcohol misuse.
  • Harsh, inconsistent parenting with high criticism, low warmth, low involvement, and low supervision.
  • Low socioeconomic status.
  • Ineffective schooling.
• Factors which may improve a poor prognosis include:
  • Recognition and adequate treatment of ADHD.
  • Appropriate school placements for those with learning difficulties.
  • Positive parenting.
• Oppositional defiant disorder can, in some cases, develop into conduct-dissocial disorder over time, particularly where presentation includes severely defiant or spiteful behaviours, or where children also have ADHD. Oppositional defiant disorder with chronic irritability and anger is associated with depressive disorders and anxiety disorders in later life.

[Blair, 2014; NICE, 2017a; Eskander, 2020; Mohan, 2023; WHO, 2023]

When to suspect a conduct disorder

• Oppositional defiant disorder is defined by ICD-11 as a persistent pattern of markedly defiant, disobedient, provocative, or spiteful behaviour that occurs more frequently than would be typical in those of comparable age, developmental level, gender, and sociocultural context. Essential diagnostic criteria are:
  • Atypical pattern of markedly noncompliant, defiant, and disobedient behaviour, for example:
    • Persistent difficulty getting along with others - arguing with authority figures; actively defying or refusing to comply with requests, directives or rules; deliberately annoying others; blaming others for mistakes; or misbehaviour.
    • Provocative, spiteful, or vindictive behaviour.
    • Extreme irritability or anger. Subtypes with and without chronic irritability-anger are described.
    • Pattern has persisted for at least 6 months.
    • The behaviour is not better accounted for by relational problems between the individual and a particular authority figure.
    • The behaviour results in significant impairment in personal, familial, social, educational, or other important areas of functioning.
• Conduct-dissocial disorder is defined by ICD-11 as a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms, rules or laws are violated. Essential diagnostic criteria are:
  • A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms, rules or laws are violated. Typically, there are multiple behaviours involved, such as:
    • Aggression towards people or animals.
    • Destruction of property (for example breaking other children's toys, breaking windows, or damaging cars.)
    • Deceitfulness or theft.
    • Serious violations of rules (for example children or adolescents repeatedly staying out all night despite parental prohibitions, repeatedly running away from home, or skipping school without permission.)
    • The behaviour must be recurrent with multiple incidents of the types of behaviours above, and persisting for at least a year.
    • The behaviour results in significant impairment of personal, familial, social, educational, occupational, or other important areas of functioning.
  • The onset of conduct-dissocial disorder may be in childhood (where the features are present and persistent before adolescence) or in adolescence (where none of the features were present prior to adolescence).
• Other specified disruptive behaviour or dissocial disorders are defined by ICD-11 as those that share primary clinical features with the disorders above, but do not fulfil the diagnostic requirements. Essential diagnostic criteria are:
  • Features of persistent behaviour problems across multiple settings.
  • Symptoms are not better accounted for by another mental, behavioural, or neurodevelopmental disorder; medical condition; or substance or medication use.
  • Behaviour has persisted for at least 6 months.
  • Behaviour is not developmentally or culturally appropriate.
  • Behaviour results in significant impairment in personal, familial, social, educational, occupational, or other important areas of functioning.
• Suspect a conduct disorder if maltreatment is not considered likely and a child or young person's parents or carers; health or social care professionals; or school, college, or peer group raise concerns about persistent, marked antisocial behaviours such as:
  • Excessive levels of fighting or bullying.
  • Cruelty to animals or people.
  • Severe destructiveness to property - causing deliberate damage or setting fires.
  • Shoplifting, stealing, and repeated lying.
  • Truancy from school and running away from home.
  • Staying out late at night without permission.
  • Unusually frequent and severe temper tantrums.
  • Defiant provocative behaviour.
  • Persistent severe disobedience.
    • Note: isolated antisocial or criminal acts are not sufficient to support a diagnosis of conduct disorders.
• Children aged 3 to 7 years — usually present with general defiance of adults’ wishes, disobedience of instructions, angry outbursts with temper tantrums, physical aggression (especially towards siblings and peers), destruction of property, arguing, blaming others for things that have gone wrong, and annoying and provoking others.
• Children aged 8 to 11 years — may present with any of the above,  as well as other behaviours such as swearing, lying, stealing outside the home, persistent breaking of rules, physical fights, bullying, cruelty to animals, and setting fires.
• Young people aged 12 to 17 years — may present with any of the above behaviours as well as hurting other people, committing crimes (such as assault, robbery using force, vandalism, burglary, stealing from cars, and car theft), running away from home, truanting from school, and misusing alcohol and drugs.

How to assess a child or young person with a suspected conduct disorder

• Assessment should be made of the child, with additional information from families, schools, and other caregivers. Consider the symptoms in all relevant settings.
• Offer the child or young person the opportunity to talk to a health professional on their own. It may be helpful to involve more than one health or social care professional to ensure a comprehensive assessment.
• Ask the child or young person and their caregivers about:
  • Core conduct disorders symptoms (for more information see the section on when to suspect a conduct disorder).
  • Current functioning at home, at school or college, and with peers.
  • Parenting (positive and negative aspects, including any use of coercive discipline).
  • Family situation.
  • Parental wellbeing (including mental health, substance misuse, criminal behaviour, and domestic violence).
  • History and family history of any past or current mental or physical health problems.
  • Concurrent stresses - bereavement, bullying, or parental separation.
• Assess for the presence of the following, which may be a differential diagnosis or comorbidity affecting management and prognosis:
  • A coexisting mental health problem (for example depression, anxiety disorders, post-traumatic stress disorder). For more information, see the CKS topics on Depression in children and Post-traumatic stress disorder.
  • A neurodevelopmental condition (in particular ADHD and autism). For more information, see the CKS topics on Attention deficit hyperactivity disorder and Autism in children.
  • A learning disability or difficulty (Information from educational settings about learning difficulties as well as behaviour is essential).
  • Communication disorders (such as speech and language problems).
  • Substance misuse. 
  • A neurological disorder (such as epilepsy or motor impairments).
• Consider the possibility of child maltreatment in any child with behavioural problems, especially if there is a marked change in the child's behaviour or emotional state in the absence of a plausible explanation.
• Assess any immediate risk to safety (any imminent risk of harm to the child or young person or to others).
• Primary care physicians with the appropriate training/expertise can consider using formal assessment tools, such as the Strengths and Difficulties Questionnaire, for the initial assessment of a child or young person with a suspected conduct disorder.

How to recognise child maltreatment

• Consider the possibility of child maltreatment in any child with behavioural problems especially if any of the following features are also present in the absence of a plausible explanation:
  • Unusual or marked change in the child's behaviour or emotional state which is different from what is expected for their age and developmental stage and is not explained by a medical condition, neurodevelopmental disorder, or stressful situation (excluding maltreatment).
  • Frequent attendance or unusual pattern of presentation to healthcare services — most commonly due to injuries, either inflicted or accidental due to inadequate supervision. Children in whom illness has been fabricated or induced are also likely to present frequently to healthcare services.
  • Injury or injuries with features that would suggest maltreatment — this could indicate physical or sexual abuse or, in some instances, neglect.
  • Evidence of sexual activity in a child or young person.
  • Harmful interaction between parent and child/young person — this could include negative hostility towards the child and rejection of the child, developing inappropriate expectations, exposure to frightening or traumatic experiences, or persistent emotional unavailability.
  • Refusal of the parent or carer to allow a child or young person to speak to a healthcare professional on their own when it is necessary for assessment.
  • The child or young person appears neglected, for example, they could have severe or persistent infestations such as scabies or head lice, they could be persistently smelly and dirty, or be failing to thrive.
• For further information on recognition of child maltreatment and how to proceed if this is suspected, see the CKS topic on Child maltreatment - recognition and management.

What is the differential diagnosis?

The differential diagnoses of disruptive behaviour or dissocial disorders include:

• Attention deficit hyperactivity disorder (ADHD) — children or young people with ADHD display symptoms of inattention associated with hyperactivity and impulsiveness that clearly interfere with, or reduce the quality of, social, academic, or occupational functioning. Unlike conduct disorder, this behaviour does not violate societal norms or the rights of others. Co-morbidity with ADHD and behavioural disorders is common. Where this is the case, adequate treatment of ADHD improves the prognosis for the behavioural disorder. For more information, see the CKS topic on Attention deficit hyperactivity disorder.
• Adjustment reaction to an external stressor — the child or young person has symptoms of conduct disturbance in reaction to an external psychological stressor such as divorce, bereavement, trauma, abuse, or adoption. Symptom onset is usually within 1 to 3 months of the psychological stressor and lasts for up to 6 months.
• Bipolar disorder — it can be difficult to distinguish conduct disorder from the symptoms of early bipolar disorder as these both include defiance and irritability in addition to a disregard for rules and behaviour that violates the rights of others.
• Depressive disorders — children and young people with depression may present with irritability and oppositional symptoms. However, unlike conduct disorder, mood is usually low and there may be associated disturbances to appetite (increased or decreased) and sleep (insomnia or increased sleep), and loss of interest or pleasure.
• Autistic spectrum disorder — emotional lability, aggressive outbursts, and destructive behaviour (often due to anxiety resulting from unexpected change in routine or sensory overload) may be seen in some children with autism. Asking about other symptoms of the autistic spectrum such as sensory hypersensitivity, impairments in social awareness or understanding, and difficulties in forming or keeping peer relationships may suggest the presence of autistic spectrum disorder. Disruptive behaviours in this situation are often associated with specific environmental factors, and non-compliance is due to features of the disorder rather than an intention to be provocative or spiteful. For more information, see the CKS topic on Autism in children.
• Dissocial and antisocial personality disorder — symptoms are similar to that of conduct disorder. However, this condition is usually diagnosed in older children (at least 17 years of age) and is more severe and pervasive. For example, all of the person's relationships are affected by their behaviour, and beliefs about their antisocial behaviour are characterized by callousness and a lack of remorse.
• Normal adolescent behaviour — Transient defiance, disobedience, and non-compliant behaviour may be part of normal development or may occur in response to significant changes. A diagnosis of a behavioural disorder depends on persistent behaviour that is not normal for that person's age, gender, and social or cultural context. There may also be criminal behaviour that is not accompanied by patterns typical of disruptive behaviour or dissocial disorders.
• Psychotic disorders — Hostility towards others may feature in a new presentation of a psychotic disorder, but other typical features would be present such as delusional thinking or hallucinations. See the CKS topic on Psychosis and schizophrenia.
• Subcultural deviance — the young person has antisocial behaviour and commits crimes, but they are not particularly aggressive or defiant.
• Substance misuse — where this is the case, the pattern of behaviour is usually limited to when illicit substances are being obtained or used. Behavioural changes may occur due to intoxication, dependence, or withdrawal. Substance misuse may co-exist with disruptive or dissocial behavioural disorders.

Scenario: Managing suspected conduct disorders

From age 36 months to 18 years.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of conduct disorders in children and young people.

Search dates

February 2018 - March 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for EBSCO Medline.

• (MH "Child Behavior Disorders")
• (MH "Conduct Disorder")
• AB (oppositional defiant*) OR TI (oppositional defiant*) 
• AB ( ((antisocial OR anti-social OR disruptive or defiant) N2 (behaviour* OR behavior*)) ) OR TI ( ((antisocial OR anti-social OR disruptive OR defiant) N2 (behaviour* OR behavior*)) ) 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.