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
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

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
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

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
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.

16. 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.

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
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.

19. 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.

20. 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.

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
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

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
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

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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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, Copyright © 1994 by the American Psychological Association. Reprinted with permission. APA is not responsible for the accuracy of this translation.

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. 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)

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

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

68. 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

69. 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

70. 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

71. 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

72. 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

73. 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