9 Conduct Problems

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)

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

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

Frequencies for Common Antisocial Behavior Figure 9.1 Parent-reported frequencies for common antisocial behaviors in clinic and nonreferred boys and girls ages 4 to 18. Source Manual for the Child Behavior Checklist/4-18 and 1991 Profile by T. M. Achenbach, 1991, pp. 131, 134, 138, 145. University of Vermont. Copyright by T. M. Achenbach. Reproduced by permission

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

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)

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

Four Categories of Conduct Problems Figure 9.2 Four categories of conduct problems Source Adapted from “Oppositional Defiant Disorder and Conduct Disorder A Meata-Analytic Review of Factor Analyses and Cross-Validation in a Clinic Sample,” by P. J. Frick, Y. Van Horn, B. B. Lahey, M.3A. G. Christ, R. Loeber, E. A. Hart, L. Tannenbaum & K. Hanson, Clinical Psychology Review, 13, 319–340. Copyright © 1993 Elsevier Science, Ltd. Reprinted with permission from Elsevier Science. Photo Credits (a) © 2011 Paul Bradbury/Jupiterimages Corporation, (b) © 2011 Weston Colton/Jupiterimages Corporation, (c) © iStockphoto.com/Patrick Herrera, (d) © Monkey Business Images/Dreamstime.com

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

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

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

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

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

Diagnostic criteria for Oppositional Defiant Disorder Table 9.1 Diagnostic criteria for oppositional defiant disorder Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association.

Diagnostic criteria for Oppositional Defiant Disorder (cont’d.) Table 9.1 Diagnostic criteria for oppositional defiant disorder (cont’d.) Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association.

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

Diagnostic Criteria for Conduct Disorder Table 9.2 Diagnostic criteria for conduct disorder Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association.

Diagnostic Criteria for Conduct Disorder (cont’d.) Table 9.2 Diagnostic criteria for conduct disorder (cont’d.) Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association.

Diagnostic Criteria for Conduct Disorder (cont’d.) Table 9.2 Diagnostic criteria for conduct disorder (cont’d.) Source Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association.

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

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

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

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

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

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

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).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Different Forms of Disruptive And Antisocial Behavior Figure 9.3 Approximate ordering of the different forms of disruptive and antisocial behavior from childhood through adolescence Source From Development and Risk Factors of Juvenile Antisocial Behavior and Delinquency by R. Loeber, 1990, ‘Clinical Psychology Review’, 10, 1–41. Copyright © 1990 Elsevier Science, Ltd. Reprinted with permission of Elsevier Science. Photo Credits © Andrewblue/Dreamstime.com; © iStockphoto.com/Christopher Futcher; Elena Rostunova/Shutterstock.com

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

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

The Changing Prevalence Of Participation In Antisocial Behavior Across The Lifespan Figure 9.4 The changing prevalence of participation in antisocial behavior across the lifespan Source From Adolescence-Limited and Life-Course-Persistent Antisocial Behavior A Developmental Taxonomy by T. E. Moffitt, 1993, 'Psychological Review', 100, 674–701. Copyright © 1993 by the American Psychological Association. Reprinted with permission. APA is not responsible for the accuracy of this translation

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

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

Genetic Influences Aggressive and antisocial behavior in humans is universal Run in families within and across generations Parents pass externalizing behaviors Heritability is higher in LCP (life-ling pattern) Heritability higher in callous- unemotional style Adoption and twin studies Indicate 50% or more of variance in antisocial behavior is hereditary Suggest contribution of genetic and environmental factors

Genetic Risks (cont-d) Anti-Social Propensity Genetic factors may be related to difficult temperament Lack of response to distress in others (unemotional) Impulsivity Tendency to seek rewards Insensitivity to punishment Genetic factors may increase the child sensitivity to environmental risks such as violence in the family , divorce, maltreatment

Prenatal Factors and Birth Complications Pregnancy and birth factors Low birth weight Malnutrition (possible protein deficiency) during pregnancy Lead poisoning Mother’s use of nicotine, marijuana, and other substances during pregnancy Maternal alcohol use during pregnancy

Neurobiological Factors Overactive behavioral activation system (BAS) and underactive behavioral inhibition system (BIS) Variations in stress-regulating mechanisms Structural and functional brain abnormalities in amygdala, prefrontal cortex, anterior cingulate, and insula Low cortical arousal and low reactivity of the autonomic nervous system This leads to fearlessness, poor response to punishment

Neurological Factors (cont-d) Brain-imaging (fMRI) studies show reduced activation in brain regions responsible for emotional processing This was found while the youngsters viewed emotional stimuli such as angry of sad faces, indicating deficits in processing social and emotional stimuli Such abnormalities underlie the social- emotional deficits seen in children with conduct disorders

Neurobiological Factors (cont’d.) Early findings suggest three neural systems are involved: Subcortical neural systems Aggressive behavior - dysfunction in the integrated functioning of brain circuits involving the amygdala Prefrontal cortex Decision-making circuits and socioemotional information processing circuits Frontoparietal regions Emotions and impulsive motivational urges

Social-Cognitive Factors Immature forms of thinking Cognitive deficiencies Cognitive distortions Deficits in facial expression recognition and eye contact Dodge and Pettit comprehensive social- cognitive framework model Cognitive and emotional processes are mediators

Steps In The Thinking And Behavior Of Aggressive Children In Social Situations Table 9.5 Steps in the thinking and behavior of aggressive children in social situations Source From A Review and Reformulation of Social information Processing Mechanism in Children’s Social Adjustment by N. R. Crick and K. A. Dodge, 1994, Psychological Bulletin’, 115, 74-101. Copyright © 1994 by the American Psychological Association. Reprinted with permission. APA is not responsible for the accuracy of this translation.

Family Factors Severe forms of antisocial behavior Are associated with a combination of child risk factors and extreme deficits in family management skills Influence of family environment is complex Reciprocal influence Child’s behavior is influenced by and influences the behavior of others Child behaviors exert greater influence on parenting behavior than the reverse

Family Factors (cont’d.) Coercion theory Parent-child interactions provide a training ground for the development of antisocial behavior Four-step escape-conditioning sequence The child learns to use increasingly intense forms of noxious behavior to avoid unwanted parental demands (coercive parent-child interaction) Children with callous-unemotional traits display significant conduct problems regardless of parenting quality

Family Factors (cont’d.) Attachment theories Children with conduct problems have little internalization of parent and societal standards There is a relationship between insecure attachments and the development of antisocial behavior

Other Family Problems Family instability and stress High family stress may be both a cause and an outcome of child’s antisocial behavior Unemployment, low SES, multiple family transitions, instability, and disruptions in parenting practices are stressors Amplifier hypothesis Parental criminality and psychopathology Aggressive and antisocial tendencies run in families within and across generations

Societal Factors Individual and family factors interact with the larger societal and cultural context in determining conduct problems Social disorganization theories Adverse contextual factors are associated with poor parenting Neighborhood and school Social selection hypothesis Media

Cultural Factors Across cultures, socialization of children for aggression is one of the strongest predictors of aggressive acts Rates of antisocial behavior vary widely across and within cultures Antisocial behavior is associated with minority status in the U.S. Likely due to low SES

Treatment and Prevention Some treatments are not very effective Office-based individual counseling and family therapy Group treatments can worsen the problem Restrictive approaches (residential treatment, inpatient hospitalization, incarceration)

Treatment and Prevention (cont’d.) Comprehensive two-pronged approach includes Early intervention/prevention programs Ongoing interventions

Effective Treatments For Children With Conduct Problems Table 9.6 Effective treatments for children with conduct problems Source Cengage Learning, 2013

Parent Management Training (PMT) Teaches parents to change the child’s behavior in the home and in other settings using contingency management techniques Focus is on: Improving parent-child interactions Promoting positive behavior Decreasing antisocial behavior Makes numerous demands on parents

Problem-Solving Skills Training (PSST) Focuses on cognitive deficiencies and distortions in interpersonal situations Five problem-solving steps are used to: Identify thoughts, feelings, and behaviors in problem social situations

Problem-Solving Skills Training (PSST) (cont’d.) Children learn to: Appraise the situation Identify self-statements and reactions Alter their attributions about others’ motivations Learn to be more sensitive to others

Multisystemic Therapy (MST) Intensive family- and community-based approach For teens with severe conduct problems who are at risk for out-of-home placement Attempts to empower caregivers to improve youth and family functioning Effective in reducing long-term rates of criminal behavior Reduces association with deviant peers

Preventive Interventions Main assumptions Conduct problems can be treated more easily and effectively in younger than older children Counteracting risk factors/strengthening protective factors at young age limits/prevents escalation of problem behaviors Costs to educational, criminal justice, health, and mental health systems are reduced

Preventive Interventions (cont’d.) Incredible Years intensive multifaceted early-intervention program for parents and teachers Support for effectiveness of early interventions in reducing later conduct problems and maintaining positive outcomes Fast Track program to prevent development of antisocial behavior in high- risk children, using five components