CONDUCT DISORDER

- - - Epidemiology:
The prevalence of Conduct Disorder (CD) in 9- to 17-year-olds in the community varies from 1 to 4 percent, depending on how the disorder is defined (Shaffer et al., 1996a). The male to female ratio has been found to range between 5:1 and 3:1 depending on the age range studied, but at all ages, it is more common in boys. Children with an early onset of the disorder, i.e., onset before age 10, are predominantly male. Peak age of onset is in late childhood and early adolescence, but onset can range from preschool to late adolescence.  Those with early onset have a worse prognosis and are at higher risk for adult antisocial personality disorder (DSM-IV, 1994; Rutter & Giller, 1984; Hendren & Mullen, 1997). CD appears to be more common in cities than in rural areas (DSM-IV, 1994).  It is estimated that at any given time about 1.3- 4 million children and adolescents are afflicted with Conduct Disorder.
- - - Clinical Features:
Children with Conduct Disorder exhibit behavior that shows a persistent disregard for the norms and rules of society. A child with CD will exhibit a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months: aggression to people and/or animals, destruction of property, deceitfulness or theft, and serious violations of rules. In addition, to meet criteria, the disturbance in behavior must cause clinically significant impairment in social, academic, or occupational functioning. For individuals 18 years or older, a diagnosis of Conduct Disorder can be made only if criteria are not met for Antisocial Personality Disorder. Children diagnosed with CD may have several associated features including; learning problems, depressed mood, hyperactivity, addiction, or other dramatic, erratic, or antisocial personality features.
The behavior interferes with performance at school or work, so that individuals with this disorder rarely perform at the level predicted by their IQ or age. Their relationships with peers and adults are often poor. They have higher injury rates and are prone to school expulsion and problems with the law. Sexually transmitted diseases are common. If removed from their homes, youth with Conduct Disorder may have difficulty staying in an adoptive or foster family or group home, and this may further complicate their development. Rates of depression, suicidal thoughts, suicide attempts, and completed suicides are all higher in children diagnosed with CD (Shaffer et al., 1996b). Girls with CD are more prone to running away from home than other girls and may become involved in prostitution.
- - - Gender Differences :
Since most studies result in a higher prevalence of Conduct Disorder among boys than in girls, alternate models for girls’ antisocial behavior have been proposed. For example, some researchers have suggested that girls are more likely to express their aggression in relational terms than in physical terms, or harming others through purposeful manipulation or damage to their peer relationships, such as by spreading rumors (e.g., Crick & Grotpeter, 1995).  On the other hand, there is little to suggest that relational and physical aggression are substitutive: both girls and boys high in one form are also likely to be high in the other (Tiet,Wasserman, Loeber, McReynolds, & Miller, 2001).  The developmental course of boys’ and girls’ antisocial behavior also appears to differ, with girls particularly less likely to show such behavior in their early years (Moffit et al., 2001).   Girls with Conduct Disorder features may have particularly adverse outcomes (e.g., Zoccolillo & Rogers, 1991) or may have more accompanying impairment (Tiet et al., 2001).  This finding has led to the awareness of a  “gender paradox†within this disorder (Eme, 1992). Gender paradox is the notion that the gender with the lower prevalence of a disorder is actually at a higher risk of poor outcomes.  The consequences of girls’ CD should not be underestimated, as the possibility for adverse impact on their offspring is increased, perhaps by means of correlated disturbances in parenting (Ehrensaft et al., 2002).
- - - Juvenile Delinquency :

While often used interchangeably, the terms “Conduct Disorder†and “Juvenile Delinquency†are not the same, though there is considerable overlap.  Conduct Disorder is a diagnostic term, and Juvenile Delinquency a legal term, and not all youth who are delinquent have CD (nor is the reverse true).   Some youth who do not meet the criteria for CD may be incarcerated for such violations as marketing controlled substances or failing to meet the conditions of their parole. These individuals are classified as juvenile delinquents but would not necessarily receive a diagnosis of CD. Youth who have committed isolated but serious acts of misconduct could be deemed delinquent without receiving a diagnosis of Conduct Disorder.  Finally, secure placement limits opportunities for current misbehavior (Wasserman et al., 2002) so that incarcerated youth may not be able to engage in misconduct during the term of their incarceration.

Recent investigations consistently demonstrate high rates of psychiatric disorder for youth in juvenile justice settings, including probation intake (Wasserman & McReynolds, 2006) (Wasserman, McReynolds, Ko, Katz, & Carpenter, 2005; Wasserman et al., 2005), detention (Teplin, Abram, McClelland, & Dulcan, 2002) and post-adjudicatory incarceration (Wasserman, McReynolds, Fisher, & Lucas, 2002; Wasserman, McReynolds, Lucas, Fisher, & Santos, 2002). While high rates of externalizing and substance use disorder are expectable injustice samples, research consistently notes elevated rates of anxiety and mood disorder as well (Wasserman et al., 2002). Again expectably, given the increases in rates of disorder, justice system youths report elevated rates of comorbidity (Abram, Teplin, Me Clelland, & Dulcan, 2003)), suicide risk (Wasserman et al., 2002), and PTSD (Abram et al., 2004).

Reference List

Abram, K. M., Teplin, L. A., Dulcan, M. K., Charles, D. R., Longworth, S. L., & McClelland, G. M. (2004). Posttraumatic stress disorder and trauma in youth in juvenile detention. Archives of General Psychiatry. 61.403-410.

Abram, K. M., Teplin, L. A., Me Clelland, G. M., & Dulcan, M. K. (2003). Comorbid psychiatric disorders in youth detention. Archives of General Psychiatry. 60. 1097-1108.

Teplin, L. A., Abram, K. M., McClelland, G. M., & Dulcan, M. K. (2002). Psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry. 59. 1133-1143.

Wasserman, G. A., McReynolds, L., Lucas, C, Fisher, P. W., & Santos, L. (2002). The Voice DISC-IV with incarcerated male youth: Prevalence of disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 41. 314-321.

Wasserman, G. A. & McReynolds, L. S. (2006). Suicide risk at juvenile probation intake. Suicide and Life Threatening Behavior. 36.239-249.

Wasserman, G. A., McReynolds, L. S., Fisher, P. W., & Lucas, C. P. (2002). Psychiatric disorders in incarcerated youths. Journal of the American Academy of Child & Adolescent Psychiatry. 42.1011.

Wasserman, G. A., McReynolds, L. S., Ko, S. J., Katz, L. M., & Carpenter, J. (2005). Gender differences in psychiatric disorders at juvenile probation intake. American Journal of Public Health. 95.131-137.

- - - Possible Causes:
The etiology of Conduct Disorder is not fully known. Studies of twins and adopted children suggest that CD has both biological (including genetic) and psychosocial components (Hendren & Mullen, 1997).Social environmental risk factors for CD include early maternal rejection, separation from parents with no adequate alternative caregiver available, early institutionalization, family neglect, abuse or violence, parents’ psychiatric illness, marital discord, large family size, crowding, and poverty (Loeber & Stouthamer-Loeber, 1986). These factors are thought to lead to a lack of attachment to the parents or to the family unit and eventually to lack of regard for the rules and rewards of society (Sampson & Laub, 1993). Physical risk factors for CD include neurological damage caused by birth complications or low birthweight, attention-deficit/hyperactivity disorder, fearlessness and stimulation-seeking behavior, learning impairments, autonomic underarousal, and insensitivity to physical pain and punishment. A child with both social deprivation and any of these neurological conditions is most susceptible to CD (Raine et al., 1998).

The risk factors for juvenile delinquency are similar to those for substance abuse, school dropout, teenage pregnancy, and juvenile violence.  These factors span across community, family, school, and individual/ peer relationships and include: the availability of firearms; community laws and norms that are favorable towards drug use, firearms, and crime; transitions and mobility in community; low neighborhood attachment and community organization; extreme economic deprivation; family history of problem behavior and family management problems; family conflict; favorable parental and peer attitudes and involvement in the problem behavior; early and persistent antisocial behavior; academic failure beginning in elementary school; lack of commitment to school; rebelliousness; early initiation of problem behavior; and constitutional factors (Catalano & Hawkins, 1995). Wasserman and Seracini (2001) examined parental deficits that interfere with proactive parenting and the co-occurrence of early child difficulties to be particularly important in the development of early-onset child behavioral problems. Family and other social-environmental factors contribute towards a child’s risk for early-onset antisocial and behavioral behaviors.  These family risk factors include: family criminality, social adversity, family violence, parental psychopathology, incompetent parenting, and physical abuse (Wasserman & Seracini, 2001).

Moffitt et al. (2001) determined that the age of onset for antisocial behavior may be associated with the pattern of symptoms and course of CD. Moffitt and her colleagues (2001) have characterized two subtypes of antisocial behavior: life-course persistent and adolescence-limited.   Childhood- onset delinquent youth are more likely to be characterized by abnormal levels of biological and environmental risk factors (i.e., hyperactivity, low IQ, and family adversity, among others), whereas adolescent-onset delinquent youth were not.  Life-course persistent antisocial behavior begins early in life when a high-risk social environment exacerbates difficult behavior of high-risk youth. Infant neuro-cognitive indicators (i.e., birth complications, low birth weight) have been found to relate to risk for life-course persistent delinquency, especially when combined with negative environmental factors such as poor parenting and social adversity (Arseneault et al., 2000b).  This relationship can be used to predict chronic aggression from childhood to adolescence (Arseneault et al., forthcoming) and violent crime (Raine, Brennen, & Mednick, 1994; Raine et al., 1996), sometimes persisting into midlife. Adolescence-limited antisocial behavior emerges along with puberty, when otherwise normally developing individuals experience a maturity gap with discrepancies between biological maturation and access to mature privileges and responsibilities, and when aspects ofpeer culture may contribute to misbehavior.  Adolescence-limited individuals are more common; their symptoms are relatively temporary, whereas the fewer individuals with life-course persistent course show more persistent and pathological symptoms (Moffitt et al., 2001).
- - - Early Intervention:
Since many risk factors for Conduct Disorder emerge in the first years of life, intervention must begin very early. Recently, screening instruments have been developed to enable earlier identification of risk factors and signs of CD in young children (Feil et al., 1995). Studies have shown a correlation between the behavior and attributes of 3 year-olds and the aggressive behavior of these children at ages 11 to 13 (Raine et al., 1998). Measurements of aggressive behaviors have been shown to be stable over time (Sampson & Laub, 1993).
- - - Treatment and Prevention:
Treatments for Conduct Disorder have focused on psychosocial interventions and parent training and in some cases the use of medication. They typically focus on helping young people understand the effect their behavior has on others and developing skills for behavioral change. Treatment is rarely brief since establishing new attitudes and behavior patterns takes time. However, early intervention that targets risks in multiple areas offers a child a better opportunity for reducing and eliminating symptoms.

Several effective psychosocial treatments have been identified for CD (Hanf, 1969; Henggeler, 1982; Henggeler et al., 1986; Kazdin et al., 1987; Kendall and Braswell, 1985; Patterson, 1982; Webster-Stratton, 1984).  Among the available psychosocial interventions, parent management training (PMT) (Patterson, 1982) has been demonstrated to be especially promising.  PMT has focused on altering coercive parent-child interactions that foster aggressive child behavior in the home and that distinguish families with antisocial children.  Another promising treatment is cognitive behavioral problem-solving skills training (PSST ) (Kendall and Braswell, 1985), which focuses on the cognitive processes and deficits that are considered to mediate maladaptive interpersonal behaviors. Kazdin (1987) combined these two treatments by providing PMT for parents and PSST for children. This combined treatment has resulted in significantly fewer aggressive and externalizing behaviors at home, at school, and greater overall adjustment in children than a contact-control group in which parents did not receive PMT but rather received contact meetings in which the child’s treatment was discussed. These positive changes were sustained for up to one year following the treatment.

Another effective psychosocial treatment is Videotape Modeling Parent Training (Webster-Stratton, 1984), which includes a videotape series of parent-training lessons and is based on the principles of parent training originally described by Hanf (1969). This treatment is administered to parents in groups with therapist-led discussions of the videotape lesson. Results show that after treatment, parents rate their children as having fewer problems and rate themselves as having a better attitude towards their children and greater self-confidence regarding their parenting role.  Observation of the children and parents showed results similar to the parent’s viewpoint.

Henggeler et al. (1986) developed multisystemic therapy (MST) , which utilizes therapeutic interventions that are based on a family-ecological systems approach to delinquency and adolescent psychopathology (Henggeler, 1982). This treatment simultaneously considers the multiple systems of which an adolescent is a part (i.e., family, peers, and extrafamilial systems) (Henggeler et al., 1986). The findings indicated that the use of a family-ecological treatment decreased conduct problems, anxious-withdrawn behaviors, immaturity, and association with delinquent peers significantly.  Family-ecological treatment differs from traditional family therapy approaches through the emphasis placed on the utilization of theory and research findings within the field of developmental psychology and child-clinical psychology (Henggeler, 1982).  The primary goal of family-ecological treatment is the reduction of an adolescent’s behavioral problems, but additional benefits occur. For example, mother-adolescent and marital relations in families are evidenced to be warmer and the adolescent typically becomes more involved in family interactions.

No medications have been demonstrated to be consistently effective in treating CD, although four drugs have been tested (Campbell et al., 1995; Kafantaris et al., 1992; Kemph et al., 1993; Klein, 1991; Klein et al., 1997b, Rifkin et al., 1989). Lithium and methylphenidate have been found (one double-blind placebo trial each) to reduce aggressiveness effectively in children with CD (Campbell et al., 1995; Klein et al., 1997b), but in two subsequent studies with the same design, the positive findings for lithium could not be replicated (Rifkin et al., 1989; Klein, 1991). In one of the latter studies, methylphenidate was superior to lithium and placebo. A third drug, carbamazepine, was found in a pilot study to be effective, but multiple side effects were also reported (Kafantaris et al., 1992). The fourth drug, clonidine, was explored in an open trial, in which 15 of 17 patients showed a significant decrease in aggressive behavior, but there were also significant side effects that would require monitoring of cardiovascular and blood pressure parameters (Kemph et al., 1993).

The Blueprints for Violence Prevention Initiative (http://ncjrs.org/html/ojjdp/jjbul2001_7_3/contents.html) is a comprehensive effort to provide communities with a set of programs whose effectiveness has been scientifically demonstrated. With the Office of Juvenile Justice and Delinquency Prevention’s (OJJDP’s) support, the Initiative also provides the information necessary for communities to begin replicating programs locally. The Initiative identified 11 prevention and intervention programs that meet a strict scientific standard of program effectiveness and have beenproven to be effective in reducing adolescent violent crime, aggression, delinquency, and substance abuse and predelinquent childhood aggression and conduct disorders. By outlining high standards of program effectiveness, reviewing outcome evaluation results for numerous programs, and identifying successful programs, the Blueprints Initiative has helped answer some of the questions about what does and does not work in violence prevention (OJJDP Blueprints for Violence Prevention, 2001).

In a recent review of prevention efforts in this arena, Wasserman and Miller (1998) conclude that identifying developmental precursors is key to in the prevention of violent behaviors.  Successful interventions and prevention programs are those that are able to attend to correlated risks in the family, community, peer, and individual domains. Such multi-modal programs have been found successful at various developmental levels (Wasserman & Miller, 1998).
- - - References
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