Conduct Disorder Danielle Herring

Changes to Conduct Disorder from DSM-IV-TR to DSM-5 Previously found under: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence Now found under: Disruptive, Impulse-Control, and Conduct Disorders No Specifier Specifier for ‘With Limited Prosocial Emotions’ Previously listed with ODD and ADHD Common core impulse-control aspect now grouped together

Conduct Disorder Found under Disruptive, Impulse-Control, and Conduct Disorders I DSM-5 Other disorders included in this chapter: Oppositional Defiant Disorder (ODD) Intermittent Explosive Disorder Pyromania Kleptomania Other Specified Disruptive, Impulse-Control, and Conduct Disorder Unspecified Disruptive, Impulse-Control, and Conduct Disorder

Conduct Disorder continued Essential Feature of CD: Repetitive and persistent pattern of behavior that violates the basic rights of others and major age- appropriate societal norms or rules. Must present for at least 3 of the following 15 criteria in the past 12 months, from any of the categories, with at least one criterion present in the past 6 months… (American Psychiatric Association, 2013) Monothetic schematic (larger diagnostic net)

Conduct Disorder continued Aggression to People and Animals Often bullies, threatens, or intimidates others. Often initiates physical fights. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). Has been physically cruel to people. Has been physically cruel to animals. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). Has forced someone into sexual activity.

Conduct Disorder continued Destruction of Property Has deliberately engaged in fire setting with the intention of causing serious damage. Has deliberately destroyed others’ property (other than by fire setting). Deceitfulness or Theft Has broken into someone else’s house, building, or car. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).

Conduct Disorder continued Deceitfulness or Theft cont. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery). Serious Violation of Rules Often stays out at night despite parental prohibitions, beginning before age 13 years. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period. Is often truant from school, beginning before age 13 years.

Conduct Disorder continued Onset types: Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years. Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10 years. Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years. Childhood-onset type: prior to age 10 years. Adolescent-onset type: no symptom prior to age 10 years. Unspecified onset: not enough information available to determine whether the onset of the first symptom was before or after age 10 years.

Conduct Disorder continued Specifier: With Limited Prosocial Emotions: To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at least 12 months in multiple relationships and settings: Lack of remorse or guilt Callous – lack of empathy Unconcerned about performance Shallow or Deficient Affect Current Severity: Mild, moderate, or severe What is Conduct Disorder?

Prevalence Rate of CD 2% - more than 10% Median = 4% 3:1 male to female Appears to be fairly consistent across various countries Rise from childhood to adolescence Per the DSM-IV-TR: “The prevalence of Conduct Disorder appears to have increased over the last decades and may be higher in urban than in rural settings. Rates vary widely depending on the nature of the population sampled and methods of ascertainment. General population studies report rates ranging from less than 1% to more than 10%. Prevalence rates are higher among males than females.”

Onset of CD Onset can occur as early as preschool years Significant symptoms usually emerge during middle childhood – middle adolescence ODD is a common diagnosis prior to the childhood- onset type of CD Onset is rare after 16 years of age Adolescent-onset/diagnosis with more mild symptoms likely to remit by adulthood Early symptoms predictive of life-course conduct problems Adolescent onset – gradually taper off

Comorbid DSM-5 Disorders Oppositional defiant disorder Attention-deficit/hyperactivity disorder Depressive disorder Bipolar disorder Specific learning disorder Anxiety disorders Substance-related disorders

DSM-V Clinical Model of CD Core Features: Aggression toward people or animals Destruction of property Deceitfulness or Theft Serious violation of rules Environmental Influences: Family & Community level risk factors Genetic Predisposition Severity: Mild Moderate Severe Secondary Features: Trait negative emotionality Poor self-control Irritability/temper outbursts Insensitivity to punishment Thrill seeking Recklessness Specifier, ‘With limited prosocial emotions’: Lack of remorse or guilt Callous – lack of empathy Unconcerned about performance Shallow or deficient affect

Literature Review

Developmental Risks 40 – 70% of adolescent boys with CD will develop APD by early adulthood (Weis, 2008) Deceitfulness, property destruction, theft Females with CD at risk for internalizing disorders Depression, anxiety, BPD (Weis, 2008) Strong association between CD and substance use (Loeber, Burke, Lahey, Winters & Zera, 2000). School discipline problems (American Psychiatric Association, 2013) Males – number of covert symptoms predicts likelihood of showing future antisocial behavior Females – symptoms of CD may interfere with development of identity and healthy relationships

Developmental Risks continued More likely to be sexually active (Brown et al., 2010) Longitudinal study conducted by Ramrakha et al., (2007), symptoms of CD, along with antisocial behavior in childhood and adolescence -> sexual risk behaviors in adulthood (variance = 64%). Females: Prostitution/Early pregnancy Likely to find antisocial partners May increase risk for DBD among offspring (Loeber et al., 2000) Disruptive behavior disorder

Etiology - Genetic Cappadocia et al., (2009) cites multiple studies that support a genetic aspect to the development of CD (i.e., Deater-Deckard, Reiss, Hetherington, & Plomin, 1997; Eaves, Silberg, Meyer, Maes, & Simonoff, 1997; Edelbrock, Rende, Plomin, & Thompson, 1995; Kim-Cohen, Caspi, Taylor, Williams, & Newcombe, 2006). Individual differences in externalizing behaviors - highly heritable at 70% (Nonshared Environment in Adolescent Development Project; Deater-Deckard et al., 1997 ).

Etiology – Genetic continued Virginia Twin Study of Adolescent Behavioral Development heritability estimates: 27–74% - parent interviews and questionnaires & 24–36% - self-report interviews and questionnaires with the twins (Eaves et al., 1997) Large sample of Caucasian twin set aged 8-16 years. Edelbrock et al. found significant genetic influence on aggressive behaviors (1995). Correlations of .75 for MZ twins and .45 for DZ twins Sample of 99 same-sex twins aged 7–15 years

Etiology – Environmental Cappadocia et al., cites several studies that show poor parenting is associated with the disruptive behaviors of CD (2009). Less involved More lenient monitoring Poor parent-child conflict resolution Inconsistent discipline (Frick et al., 1992; Haapasalo & Tremblay, 1994; Wasserman et al., 1996).

Etiology – Environmental continued The DSM-5 also cites these additional family-level risk factors: Parental rejection and neglect Harsh discipline Physical or sexual abuse Early institutional living Frequent changes of caregivers Large family size Certain kinds of familial psychopathology  (American Psychiatric Association, 2013)

Etiology – Social Factors CD diagnosis more prevalent in children from families of low SES (8%, n=87) (Lahey et al., 1999). Adolescents with CD from low SES backgrounds more likely to develop APD in adulthood. Lahey et al. (2005): 65% Loeber et al., (2000) cites multiple studies that found CD more common in high crime-rate areas (Lahey et al., 1999, Loeber and Farrington, 1998; Sampson et al., 1997). Prevalence rates of CD likely highest in worst inner- city neighborhoods (Loeber et al., 2000).

Etiology – Social Factors continued Poor/disadvantaged neighborhoods Negative community influences: Drug availability Association with adults that partake in crimes Parent, peers, and neighborhood are all associated factors of CD (Cappadocia et al., 2009) Peer rejection Association with deviant peers (Cappadocia et al., 2009).

Etiology - Neurological Structural deficits in brain areas: Frontal and temporal areas Reduced right temporal lobe and right temporal grey matter volume (Kruesi, Casanova, Mannheim & Johnson-Bilder, 2004; Matthys, W., Vanderschuren, L. J., & Schutter, D. G., 2013). Limbic system: Amygdala and anterior cingulate cortex Less activation in left amygdala and deactivation of ACC (Sterzer et al., 2005) Right temporal lobe – empathy Limbic system – associated with aggressive behaviors

Etiology – Neurological continued Lower serotonin (5-HT) levels (Cappadocia et al., 2009) Associated with aggression Lower ANS functioning Decreased resting heart rate and skin conductance Meta-analysis of 40 studies showed low resting HR best replicated biological correlate of CD: average effect size of -.44 (Ortiz & Raine, 2004). HPA Axis involvement Lower levels of cortisol have been associated with CD Reduced serotonin – behavioral disinhibition, impulsive behaviors and aggression Low resting heart rate, SC – underarousal leads to behavioral disinhibition as less likely to avoid behaviors with negative consequences. Atypical ANS functioning also associated with other mental health disorders - depression and schizophrenia. HPA – low cortisol more aggressive symptoms of CD

Structural Brain Differences - Males Sixty-five male adolescents with conduct disorder were re-cruited from schools, pupil referral units, and the Cambridge Youth Offending Service, Cambridge, United Kingdom. A healthy comparison group (no history of conduct disorder/oppositional defiant disorder and no current psychiatric illness) of 27 male adolescents, matched for IQ, was recruited from schools and colleges. (N=75) Voxel-based morphometry analysis was performed using SPM5. The amygdala, insula, anterior cingulate, and orbitofrontal cortex were defined as the a priori regions of interest. The number of voxels within each region of interest was: amygdala: 248; insula: 1,858; anterior cingulate: 1,399; orbitofrontal cortex: 3,645.  To decompose the group effects, the study first compared the combined conduct disorder group (early-onset plus adolescent-onset) with the healthy comparison group. Relative to comparison subjects, the combined conduct disorder group showed reduced gray matter volume in the bilateral amygdala. Relative to comparison subjects, both early- and adolescent-onset conduct disorder participants showed reduced right amygdala gray matter volume. Adolescent-onset participants also displayed reduced left amygdala volume, and reduced left amygdala volume in early-onset participants. The function of grey matter is to route sensory or motor stimulus to interneurons of the CNS in order to create a response to the stimulus through chemical synapse activity. gray matter volume reductions in the bilateral in a combined group of participants with conduct disorder significant bilateral amygdala volume reduction in participants with early-onset conduct disorder relative to healthy comparison subjects; significant bilateral amygdala volume reduction in participants with adolescent-onset conduct disorder relative to healthy comparison subjects; and the mean value for right amygdala gray matter volume in each group. The color bars represent T statistics. Fairchild, G., Passamonti, L., Hurford, G., Hagan, C. C., von dem Hagen, E. H., van Goozen, S. M., & ... Calder, A. J. (2011). Brain structure abnormalities in early-onset and adolescent-onset conduct disorder. The American Journal Of Psychiatry, 168(6), 624-633. doi:10.1176/appi.ajp.2010.10081184

Structural Brain Differences - Females Female adolescents with CD (n = 22) and healthy control participants matched in age, performance IQ and handedness (n = 20). Twenty-two female adolescents with CD aged 14–20 years were recruited from schools, pupil referral units and the Cambridge Youth Offending Service. A healthy control group (HC; no history of CD/ODD and no current psychiatric illness) of 21 female adolescents, matched for age, handedness and performance IQ, was recruited from schools.  Relative to controls, the CD group showed reduced grey matter volume in bilateral anterior insula and right striatum. The table provides statistics and coordinates for these group differences. Panel A displays bilateral anterior insula and right striatal volume differences in coronal format, whereas panel B depicts the results in axial format. The color bar, which ranges from red to white, represents T statistics.  Fairchild, G., Hagan, C. C., Walsh, N. D., Passamonti, L., Calder, A. J., & Goodyer, I. M. (2013). Brain structure abnormalities in adolescent girls with conduct disorder. Journal Of Child Psychology And Psychiatry, 54(1), 86-95. doi:10.1111/j.1469-7610.2012.02617.x

Gender Differences Different symptom clusters can be noted between sexes. Males: Physical aggression: Fighting, stealing, vandalism, and school discipline problems (Loeber et al., 2000). Females: Indirect, verbal, and relational aggression: Alienation, ostracism, and character defamation aimed at ‘friends’ (Loeber et al., 2000) Lying, truancy, running away, substance use, and prostitution (Maughan et al. 2004)

Gender Differences continued Prevalence data of ODD/CD in community sample divided between boys and girls. Popular to common belief, CD also relatively common in females.

Developmental Pathways Model Loeber & Hay’s developmental pathways model (1994) Within-individual changes in patterns of aggression. Establish development toward violence. Sequence of aggressive acts of increasing severity over time. Loeber & Assoc. found evidence for 3 developmental pathways for males during childhood/adolescence. 1 – Overt pathway: aggression is first stage, physical fighting, and then violence (attacking someone, rape) 2 – Covert pathway: escalates through concealed behaviors 3 – Authority conflict pathway: conflict with and avoidance of authority figures. As you go up the model, fewer males stay in the pathway. Important to distinguish between those that are ‘experimenting’ or peer pressured and those where the aggression persists over time.

Callous-Unemotional Traits Lack of guilt, lack of concern about feelings of others, lack of concern about performance in important activities and shallow/deficient affect Similar traits used to define construct of psychopathy in adults Deficits in processing negative emotional stimuli More fearless and thrill-seeking Lower levels of anxiety More severe, stable, and aggressive pattern of behavior Higher rates of aggressive behavior and cruelty ratings (Kahn, R. E., Frick, P. J., Youngstrom, E., Findling, R. L., & Youngstrom, J., 2012). The traits can interfere with the normal development of consciousness and place child at risk for severe and aggressive pattern of antisocial behavior. Lower anxiety – less distressed by effects of their behavior.

Callous-Unemotional Traits continued In a UK study of 7,977, aged 5-16 (2009): 2% diagnosed with CD Of those, 46% showed 2 or more C/U traits Those with C/U traits – more severe behavioral disturbance In a sample of 1,862 high-risk girls, aged 6-8: Of those that were diagnosed with CD, 26% met criteria for CU Those with CU showed more bullying and relational aggression (Frick, 2012 referencing Pardini, Stepp, Hipwell, Stouthamer-Loeber, & Loeber, in press)

C/U Traits & Outcomes A study conducted by McMahon, Kotler, and Witkiewitz (2010) found that: N = 891 Higher levels of C/U traits predicted: Higher levels of self-reported delinquency More juvenile and adult arrests Greater number of APD criteria met Higher likelihood of APD diagnosis

C/U Traits & Prevention Frick (2012): Interventions need to be comprehensive, individualized, and intense Youths with CU traits less likely to respond and participate in typical treatment Cognitive-behavioral treatment Parent management training School consultation Peer relationship development Crisis management Medication for ADHD (if applicable) (Kolko & Pardini, ,2010)

C/U Traits & Prevention Munoz, Pakalniskiene, and Frick (2011): Parents’ monitoring behaviors influence conduct problems? Conduct problems influenced how parents monitored behavior? Important for high levels of CU traits as that may influence parental behavior more than children without 75 parents & 81 children providing data Parents with poor knowledge of child’s activities – controlled them less Children less likely to provide information to parents More resistant to punishment by parents Prevention – target early relationship between parent and child

Other Models of CD Cappadocia et al.’s hypothesized developmental model:

My Model of CD Comorbidity ODD Biological Influences ADHD Genetics Neurological Impairments/ C-U Traits Structural brain differences Neurochemical dysregulation Lack of remorse or guilt Callous – lack of empathy Unconcerned about performance Shallow or deficient affect Core Features: Poor self-control Irritability/temper outbursts Insensitivity to punishment Thrill seeking Recklessness Secondary/Features: Aggression toward people or animals Destruction of property Deceitfulness or Theft Serious violation of rules Environmental Influences: Family & Community level risk factors SES-related factors Severity: Mild Moderate Severe Antisocial Personality Disorder

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Brown, L. K., Hadley, W., Stewart, A., Lescano, C., Whiteley, L., Donenberg, G., & DiClemente, R. (2010). Psychiatric disorders and sexual risk among adolescents in mental health treatment. Journal Of Consulting And Clinical Psychology, 78(4), 590-597. doi:10.1037/ a0019632 Cappadocia, M., Desrocher, M., Pepler, D., & Schroeder, J. H. (2009). Contextualizing the neurobiology of conduct disorder in an emotion dysregulation framework. Clinical Psychology Review, 29(6), 506-518. doi:10.1016/j.cpr. 2009.06.001

References Deater-Deckard, K., Reiss, D., Hetherington, E., & Plomin, R. (1997). Dimensions and disorders of adolescent adjustment: A quantitative genetic analysis of unselected samples and selected extremes. Child Psychology & Psychiatry & Allied Disciplines, 38(5), 515-525. doi:10.1111/j. 1469-7610.1997.tb01538.x Eaves, L. J., Silberg, J. L., Maes, H. H., Simonoff, E., Pickles, A., Rutter, M., & ... Hewitt, J. K. (1997). Genetics and developmental psychopathology: 2. The main effects of genes and environment on behavioral problems in the Virginia Twin Study of Adolescent Behavioral Development. Child Psychology & Psychiatry & Allied Disciplines, 38(8), 965-980. doi:10.1111/j. 1469-7610.1997.tb01614.x Edelbrock, C., Rende, R., Plomin, R., & Thompson, L. (1995). A twin study of competence and problem behavior in childhood and early adolescence. Child Psychology & Psychiatry & Allied Disciplines, 36(5), 775-785. doi:10.1111/j.1469-7610.1995.tb01328.x

References Fairchild, G., Passamonti, L., Hurford, G., Hagan, C. C., von dem Hagen, E. H., van Goozen, S. M., & ... Calder, A. J. (2011). Brain structure abnormalities in early-onset and adolescent-onset conduct disorder. The American Journal Of Psychiatry, 168(6), 624-633. doi:10.1176/appi.ajp. 2010.10081184 Fairchild, G., Hagan, C. C., Walsh, N. D., Passamonti, L., Calder, A. J., & Goodyer, I. M. (2013). Brain structure abnormalities in adolescent girls with conduct disorder. Journal Of Child Psychology And Psychiatry, 54(1), 86-95. doi:10.1111/j.1469-7610.2012.02617.x Frick, P. J., Lahey, B. B., Loeber, R., Stouthamer-Loeber, M., Christ, M. G., & Hanson, K. (1992). Familial risk factors to oppositional defiant disorder and conduct disorder: Parental psychopathology and maternal parenting. Journal Of Consulting And Clinical Psychology, 60(1), 49-55. doi: 10.1037/0022-006X.60.1.49 Haapasalo, J., & Tremblay, R. E. (1994). Physically aggressive boys from ages 6 to 12: Family background, parenting behavior, and prediction of delinquency. Journal Of Consulting And Clinical Psychology, 62(5), 1044-1052. doi:10.1037/0022-006X.62.5.1044

References Kahn, R. E., Frick, P. J., Youngstrom, E., Findling, R. L., & Youngstrom, J. ( 2012). The effects of including a callous–unemotional specifier for the diagnosis of conduct disorder. Journal Of Child Psychology And Psychiatry, 53(3), 271-282. doi:10.1111/j.1469-7610.2011.02463.x Kim-Cohen, J. J., Caspi, A. A., Taylor, A. A., Williams, B. B., Newcombe, R. R., Craig, I. W., & Moffitt, T. E. (2006). MAOA, maltreatment, and gene- environment interaction predicting children's mental health: New evidence and a meta-analysis. Molecular Psychiatry, 11(10), 903-913. doi: 10.1038/sj.mp.4001851 Kruesi, M. P., Casanova, M. F., Mannheim, G., & Johnson-Bilder, A. (2004). Reduced temporal lobe volume in early onset conduct disorder. Psychiatry Research: Neuroimaging, 132(1), 1-11. doi:10.1016/j.pscychresns. 2004.07.002 Lahey, B.B., Miller, T.L., Godran, R.A., Riley, A.W. (1999). Handbook of Disruptive Behavior Disorders. New York: Plenum.

References Loeber, R., Burke, J. D., Lahey, B. B., Winters, A., & Zera, M. (2000). Oppositional defiant and conduct disorder: A review of the past 10 years, Part I. Journal Of The American Academy Of Child & Adolescent Psychiatry, 39(12), 1468-1484. doi 10.1097/00004583- 200012000-00007 Loeber, R., & Farrington, D.P. (1998). Serious and Violent Juvenile Offenders: Risk Factors and Successful Interventions. Thousand Oaks, CA: Sage. Matthys, W., Vanderschuren, L. J., & Schutter, D. G. (2013). The neurobiology of oppositional defiant disorder and conduct disorder: Altered functioning in three mental domains. Development And Psychopathology, 25(1), 193-207. doi:10.1017/S0954579412000272 Maughan, B., Rowe, R., Messer, J., Goodman, R., & Meltzer, H. (2004). Conduct Disorder and Oppositional Defiant Disorder in a national sample: Developmental epidemiology. Journal Of Child Psychology And Psychiatry, 45(3), 609-621. doi:10.1111/j.1469-7610.2004.00250.x

References Ramrakha, S., Bell, M. L., Paul, C., Dickson, N., Moffitt, T. E., & Caspi, A. (2007). Childhood behavior problems linked to sexual risk taking in young adulthood: A birth cohort study. Journal Of The American Academy Of Child & Adolescent Psychiatry, 46(10), 1272- 1279. doi:10.1097/chi. 0b013e3180f6340e Sampson, R.J., Raudenbusch, S.W., Earls, F., (1997). Neighborhoods and violent crime: a multilevel study of collective efficacy. Science, (277), 918-924. Sterzer, P., Stadler, C., Krebs, A., Kleinschmidt, A., & Poustka, F. (2005). Abnormal Neural Responses to Emotional Visual Stimuli in Adolescents with Conduct Disorder. Biological Psychiatry, 57(1), 7-15. doi:10.1016/ j.biopsych.2004.10.008 Wasserman, G., Miller, L. S., Pinner, E., & Jaramillo, B. (1996). Parenting predictors of early conduct problems in urban, high-risk boys. Journal Of The American Academy Of Child & Adolescent Psychiatry, 35(9), 1227-1236. doi:10.1097/00004583-199609000-00020 What is Conduct Disorder? [Video file]. Retrieved from http:// www.youtube.com/watch?v=g58qUHEq6fU