Conduct Problems

1. 9 Conduct Problems

2. Description of Conduct Problems • Age-inappropriate actions and attitudes that violate family expectations, societal norms, and personal or property rights of others • These disruptive and rule-violating behaviors range from: • Annoying minor behaviors (e.g., temper tantrums) to serious antisocial behaviors (e.g., vandalism, theft, and assault)

3. Description of Conduct Problems (cont’d.) • We must consider many types, pathways, causes, and outcomes of conduct problems • Are associated with unfortunate family and neighborhood circumstances • Circumstances do not excuse the behavior, but help us understand and prevent it

4. Context • Antisocial behaviors appear and decline during normal development • Behaviors vary in severity, from minor disobedience to fighting • Some may decrease with age; others increase with age and opportunity • Are more common in boys in childhood • Children who are the most physically aggressive in early childhood maintain relative standing over time

5. Frequencies for Common Antisocial Behavior

6. Social and Economic Costs • Conduct problems are the most costly mental health problem in North America • Early, persistent, and extreme antisocial behavior occurs in about 5% of children • These children account 50% of all crime in the U.S. and approximately 30-50% of clinic referrals • Annual public costs (healthcare, juvenile justice, and educational systems) are $10,000 per child

7. Legal Perspectives • Juvenile delinquency • Legal definitions exclude antisocial behaviors of very young children • Including property crimes (e.g. vandalism, theft), violent crimes (robbery, aggravated assault, homicide) • Minimum age of responsibility is 12 (in most states) • Only a subgroup of children meeting legal definition of delinquency also meet definition of a mental disorder (needs to show persistent pattern)

8. Psychological Perspectives • Conduct problems fall on a continuous dimension • Externalizing dimension: Impulsive and overactive • “Rule-breaking behavior”: running away, setting fires, stealing, dugs, vandalism, skipping school • “Aggressive behavior” : Fighting , destructiveness, disobedience, defiance, threatening • Overt (visible) –covert (hidden) dimension • (Most children with CD display both) • Destructive-nondestructive dimension • Crossing the overt-covert with the destructive-nondestructive • Yields four categories of conduct problems

9. Four Categories of Conduct Problems

10. Examples of the two dimensions • Covert (hidden)- Destructive: Property violations: vandalism, stealing, fires, cruelty to animals; also lying • Covert- Non-Destructive: Runway, truancy, substance use, breaks rules • Overt (Open)-Destructive: Aggression, fight, bullying, Spiteful • Overt- Non-Destructive (oppositional) Argues, temper, defies, stubborn, annoys, touchy

11. Psychiatric Perspectives • Conduct problems are viewed as distinct mental disorders based on DSM symptoms • Disruptive behaviors are described as persistent patterns of antisocial behavior • Represented by the categories of Conduct Disorder (CD) and Oppositional Defiant Disorders (ODD) • The diagnosis of antisocial personality disorder (APD) is relevant to understanding childhood conduct and their adult outcomes

12. Public Health Perspectives • Blends the legal, psychological, and psychiatric perspectives with public health concepts of prevention and intervention • Goal • To reduce injuries, deaths, personal suffering, and economic costs associated with youth violence • Cut across disciplines to: • Understand conduct problems in youths • Determine how these problems can be treated and prevented

13. DSM-5 Defining Features • Two DSM-5 disruptive behavior disorders • Oppositional defiant disorder (ODD) • Conduct disorder (CD) • Both have been found to predict future psychopathology and enduring impairment in life functioning

14. Oppositional Defiant Disorder • Age-inappropriate recurrent pattern of stubborn, hostile, disobedient, and defiant behaviors • Usually appears by age 8 • Severe ODD behaviors can have negative effects on parent-child interactions • Symptoms can be grouped into • 1)Negative affect ( angry, irritable mood) • 2) Defiance (defiant/strong-head behavior

15. Diagnostic criteria for Oppositional Defiant Disorder

16. Diagnostic criteria for Oppositional Defiant Disorder (cont’d.)

17. Conduct Disorder • Repetitive, persistent pattern of severe aggressive and antisocial acts • May have co-occurring problems, e.g., ADHD, academic deficiencies, and poor peer relations • Family child-rearing practices may contribute to problems • Parents feel the children are out of control and feel helpless to do anything about it

18. Diagnostic Criteria for Conduct Disorder

19. Diagnostic Criteria for Conduct Disorder (cont’d.)

20. Diagnostic Criteria for Conduct Disorder (cont’d.)

21. Conduct Disorder Age of Onset • Children with childhood-onset CD display at least one symptom before age 10 • More likely to be boys • Show more aggressive symptoms • Account for disproportionate amount of illegal activity • Persist in antisocial behavior over time

22. Conduct Disorder Age of Onset (cont’d.) • Children with adolescent-onset CD • As likely to be girls as boys • Do not show the severity or psychopathology characterizing the early-onset group • Are less likely to commit violent offenses or persist in their antisocial behavior over time

23. Are CD and ODD Separate? • Nearly half of all children with CD have no prior ODD diagnosis • Most children who display ODD do not progress to more severe CD • For most children, ODD: • Is an extreme developmental variation • Is a strong risk factor for later ODD • Does not signal an escalation to more serious conduct problems

24. Antisocial Personality Disorder (ADP) and Psychopathic Features • Pervasive pattern of disregard for and violation of the rights of others; involvement in multiple illegal behaviors • As many as 40% of children with CD later develop APD • Adolescents with APD may display psychopathic features • Signs of lack of conscience occur as young as 3-5 years

25. Antisocial Personality Disorder (ADP) and Psychopathic Features (cont’d.) • A subgroup of children with CD are at risk for extreme antisocial and aggressive acts and for poor long-term outcomes • Display callous and unemotional (CU) interpersonal style • Lack guilt and empathy; do not show emotions; display narcissism and impulsivity; and lack behavioral inhibition • Different developmental processes may underlie behavioral and emotional problems

26. Associated Characteristics • Many factors are associated with conduct problems in youths • Cognitive and verbal deficits • School and learning problems • Self-esteem deficits • Peer problems • Family problems • Health-related problems

27. Cognitive and Verbal Deficits • Most children with conduct problems have normal intelligence • Verbal deficits are present in early development: may interfere with self-control, emotional regulation, receptive listening, expressive speech • Deficits in executive functioning • Co-occurring ADHD may be a factor • Types of executive function exhibited may differ - cool: attention, working memory, planning and inhibition, (such as in ADHD) versus hot executive functions: involve incentive and motivation (more often in CD).

28. Deficits in Executive Functions • Rarely consider the consequences of their behavior or the impact on others • Fail to inhibit their impulsivity • Fail to consider future rewards • Fail to adapt their action to future circumstances • May be related to the comorbidity with ADHD

29. School and Learning Problems • Underachievement, grade retention, special education placement, dropout, suspension, and expulsion • Relationship between conduct problems and underachievement is firmly established by adolescence • May lead to anxiety or depression in young adulthood

30. Family Problems • General family disturbances • Specific disturbances in parenting practices and family functioning • High levels of conflict are common in the family, especially between siblings • Lack of family cohesion and emotional support • Deficient parenting practices • Parental social-cognitive deficits

31. Peer Problems • Young children with conduct problems display poor social skills and verbal and physical aggression toward peers • Often rejected by peers, although some are popular • Children rejected in primary grades are five times more likely to display conduct problems as teens • Some become bullies

32. Peer Problems (cont’d.) • Often form friendships with other antisocial peers • Predictive of conduct problems during adolescence • Underestimate own aggression and its negative impact, and overestimate others’ aggression toward them

33. Peer Problems (cont’d.) • Reactive-aggressive children display hostile attributional bias • Proactive-aggressive view their aggressive actions as positive

34. Self-Esteem Deficits • Low self-esteem is not the primary cause of conduct problems • Instead, problems are related to inflated, unstable, and/or tentative view of self • Youths with conduct problems may experience high self-esteem • Over time may permit them to rationalize their antisocial conduct

35. Health-Related Problems • High risk for personal injury, illness, drug overdose, sexually transmitted diseases, substance abuse, and physical problems as adults • Rates of premature death (before age 30) • Are 3 to 4 times higher in boys with conduct problems

36. Health-Related Problems (cont’d.) • Early onset and persistence of sexual activity and sexual risk-taking by age 21 • Substance use disorders and adolescent antisocial behavior are strongly associated • Childhood conduct problems are a risk factor for adolescent and adult substance abuse • Mediated by drug use and delinquency during early and late adolescence

37. Accompanying Disorders and Symptoms • Attention-Deficit/Hyperactivity Disorder • More than 50% of children with CD also have ADHD • Possible reasons for overlap • A shared predisposing vulnerability may lead to both ADHD and CD • ADHD may be a catalyst for CD • ADHD may lead to childhood onset of CD • Research suggests that CD and ADHD are distinct disorders

38. Accompanying Disorders and Symptoms (cont’d.) • Depression and anxiety • About 50% of children with conduct problems also have depression or anxiety • ODD best accounts for the connection between conduct problems and depression • Increasing severity of antisocial behavior is associated with increasing severity of depression and anxiety • Anxiety may serve as a protective factor to inhibit aggression

39. Prevalence • ODD is more prevalent than CD during childhood; by adolescence, prevalence is equal • Lifetime prevalence rates • 12% for ODD (13% for males, 11% for females) • 8% for CD (9% for males, 6% for females) • Prevalence for CD and ODD across cultures of Western countries are similar

40. Gender • Gender differences are evident by 2-3 years of age • During childhood, rates of conduct problems are about 2-4 times higher in boys • Boys have earlier age of onset and greater persistence • Early symptoms for boys are aggression and theft; early symptoms for girls are sexual misbehaviors

41. Explaining Gender Differences • Possible explanations • Genetic, neurobiological, environmental risk factors, and definitions of conduct problems that emphasize physical violence • Girls use indirect, relational forms of aggression • Early maturing boys and girls are at risk for recruitment into delinquent behavior by peers

42. General Progression • Earliest sign is difficult temperament in infancy • Hyperactivity and impulsivity during preschool ad early school years • Oppositional and aggressive behaviors peak during preschool years • Diversification - new forms of antisocial behavior develop over time

43. General Progression (cont’d.) • Covert conduct problems begin during elementary school • Problems become more frequent during adolescence

44. General Progression (cont’d.) • Some children break from the traditional progression • About 50% of children with early conduct problems improve • Some don’t display problems until adolescence • Some display persistent low-level antisocial behavior from childhood/adolescence through adulthood

45. Different Forms of Disruptive And Antisocial Behavior

46. Two Common Pathways • Life-course-persistent (LCP) path begins early and persists into adulthood • Antisocial behavior begins early • Subtle neuropsychological deficits heighten vulnerability to antisocial elements in social environment • Complete, spontaneous recovery is rare after adolescence • Associated with family history of externalizing disorders

47. Two Common Pathways (cont’d.) • Adolescent-limited (AL) path begins at puberty and ends in young adulthood • Less extreme antisocial behavior, less likely to drop out of school, and have stronger family ties • Delinquent activity is often related to temporary situational factors, especially peer influences

48. The Changing Prevalence Of Participation In Antisocial Behavior Across The Lifespan

49. Adult Outcomes • 50% of active offenders decrease by early 20s, and 85% decrease by late 20s • Negative adult outcomes are seen, especially for those on the LCP path • Males - criminal behavior, work problems, and substance abuse • Females - depression, suicide, and health problems

50. Causes • Early theories focused on a child’s aggression • No single theory explains all forms of antisocial behavior • Today conduct problems are seen as resulting from: • The interplay among a predisposing child, family, community, and cultural factors operating in a transactional fashion over time