Conduct problems in children and adolescents are among the most common referrals to mental health agencies and are a leading cause for concern among family, social, and legal systems in the United States. Conduct problems can be defined as externalizing behaviors that are oppositional, defiant, aggressive, and/or antisocial, including verbal or physical violence, threatening or bullying, destruction of property, and other delinquent acts. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (DSM-IV-TR), classifies problems of conduct in the broad category of Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. The disorders attention deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder are included in the subcategory Attention-Deficit and Disruptive Behavior Disorders.
The Nature of Conduct Disorder
Conduct disorder, as defined by the DSM-IV-TR, is a persistent and recurring pattern of behavior in which an individual violates the basic rights of others or major age-appropriate societal norms or rules. It is important to note that although behaviors such as lying, aggression, and defiant behaviors occur throughout typical childhood development, the behaviors that are associated with conduct disorder significantly interfere with social, academic, or occupational functioning of the individual and are more severe than those associated with normal developmental stages. The behaviors associated with conduct disorder are categorized into four main groups: aggression toward people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. In order for an individual to be diagnosed with conduct disorder, three or more of the following criteria must have been met within the past 12 months, and at least one must have been present in the past 6 months: (1) often bullies, threatens, or intimidates others; (2) often initiates physical fights; (3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun); (4) has been physically cruel to people; (5) has been physically cruel to animals; (6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery; (7) has forced someone into sexual activity; (8) has deliberately engaged in fire setting with the intention of causing serious damage; (9) has deliberately destroyed others’ property (other than by fire setting); (10) has broken into someone else’s house, building, or car; (11) has lied often to obtain goods or favors or to avoid obligations (i.e., cons others); (12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery); (13) often stays out at night despite parental prohibitions, beginning before age 13 years, (14) has run away from home overnight at least twice while living in a parental or parental surrogate home (or once without returning for a lengthy period); and (15) is often truant from school, beginning before age 13 years.
There are generally thought to be two types of conduct disorder: childhood-onset and adolescent-onset. The childhood-onset type occurs when the characteristics of conduct disorder begin prior to age 10; in the adolescent-onset type, symptoms occur after the age of 10. (Note: An individual who is 18 years or older may be diagnosed with a conduct disorder as long as criteria for antisocial personality disorder [APD]—a pattern of disregard for and violation of the rights of others occurring since age 15—are not met.) The presentation of conduct disorder in children or adolescents is multifaceted in terms of the number and types of symptoms, the risk factors and protective factors associated with the individual, and in the degree of severity of the behaviors.
Conduct Disorder Prevalence and Comorbidity
The prevalence of conduct disorder ranges from 1% to 10% of the general population and about 26% in the clinical setting. More specifically, recent research has found a lifetime prevalence rate of 9.5% and a more frequent rate of occurrence in males (12%) than in females (7.1%). Conduct disorder is also more prevalent among older children and adolescents than in younger children. Conduct disorder often co-occurs with other psychological disorders, and individuals diagnosed with conduct disorder are often at risk for other problems. It remains unclear whether problems with conduct cause comorbid disorders, or whether comorbid disorders increase the risk for conduct disorder; however, links have been found between conduct disorder and many comorbid disorders. For example, children with conduct disorder often exhibit ADHD symptoms such as impulsivity and hyperactivity; however, children diagnosed with ADHD behaviors do not necessarily engage in severe antisocial behaviors. Often, the presence of ADHD symptoms seems to trigger problems with conduct. Additional disorders associated with conduct disorder include internalizing disorders such as depression and anxiety, learning dis-abilities or academic underachievement, substance abuse, and adjustment disorders. Nearly half of individuals diagnosed with conduct disorder also meet criteria for another disorder.
Assessment of Conduct Disorder
The assessment of conduct problems is a complex process that requires a comprehensive psychological evaluation of the child in many contexts using multiple assessment tools and techniques. Evaluations typically involve diagnostic interviews with parents, teachers, family members, or other individuals working closely with the child. Clinical interviews with the child may also be incorporated, making note that youth do not always view their behavior as problematic or have insight about the impact their behavior has on others. Standardized behavior rating scales (e.g., Behavior Assessment System for Children, Child Behavior Checklist) and self-report measures of behavior and personality (Minnesota Multiphasic Personality Inventory-Adolescent [MMPI-A]) are often utilized in order to gather reliable ratings of the child’s emotional and behavioral problems as observed by the child and by others. Direct observations of a child’s behavior in structured and unstructured settings are also an integral part of the assessment procedure. An extensive review of school, legal, medical, and psychological treatment records is recommended as well as complete background information and family history. An assessment should also evaluate the presence of comorbid conditions that typically occur with conduct disorder and should take into account the cultural context of an individual. It is essential to identify and evaluate contextual factors that influence the child’s behavior patterns and functioning, including both internal and external factors.
Course of Conduct Disorder
Evidence suggests a developmental progression that occurs with conduct problems. In particular, the progression from ODD to conduct disorder and from conduct disorder to APD has been studied extensively. The criteria for ODD include defiant and oppositional behaviors toward authority figures, although symptoms are not as severe as the behaviors in conduct disorder. About 90% of children who are diagnosed with conduct disorder also meet criteria for ODD. Research suggest that ODD could be a precursor to conduct disorder, because most cases of conduct disorder have previously met the criteria for ODD, yet most individuals with ODD do not necessarily progress to a conduct disorder. A similar pattern is found with the progression from conduct disorder to APD (which is associated with a greater severity of sociopathy or violation of societal rules than in conduct disorder). Adults with APD have almost always previously met criteria for conduct disorder, and 25% to 40% of conduct-disordered children and adolescents will progress to APD in adulthood.
Accordingly, the prognosis for conduct disorder is not optimistic, and evidence suggests that over the course of the life span, conduct disorder is relatively stable. There is a particularly negative prognosis for childhood-onset conduct disorder; individuals who develop significant conduct problems at an early age continue to exhibit more severe aggression and delinquency in middle childhood and adolescence. High recidivism rates are also associated with conduct disorders.
Conduct Disorder Risk Factors
A variety of risk factors are associated with conduct disorder, including both internal and external factors.
Internal factors involve individual influences such as genetic and psychobiological influences and cognitive and social cognitive characteristics. Genetic and biological influences on conduct disorder have been shown to have an indirect influence on the development of difficulties in children. Heritability traits for aggression increase the possibility of antisocial behaviors in children as well as the possibility of neuropsychological and neurophysiological problems. Cognitive problems such as low IQ have been associated with conduct problems, as have deficits in executive functioning (such as ADHD).
Social cognitive characteristics such as social-emotional functioning, or how individuals perceive their social world, have also been related to conduct disorders. Often, conduct-disordered individuals have problems with information processing and identifying social cues; they make hostile attributions or misinterpret the intent of others’ behavior. These characteristics are associated with increased aggression and negative interactions with others such as parents and peers.
External factors include family, parent, and community sources. Dysfunction in the family structure is key to the development of aggression and antisocial behavior among children and adolescents. Family dissolution, single parent homes, and large family size often put strains on the individual’s environment, and this precipitates problem behaviors. In addition, the interaction between the child and parent, the overall functioning of the family, and parent characteristics are also associated with problems in conduct. Parental psychopathology (i.e., substance abuse and depression) and criminal behavior of parents are associated with increased aggression and antisocial behaviors in children. Inconsistent parenting techniques, inadequate supervision of children, and low parental involvement are characteristics of parents of youth with conduct disorders. Physical and sexual abuse is more common among the families of children with conduct disorder, which also contributes to family violence and aggressive behaviors. Community factors contributing to conduct disorders include low socioeconomic status (e.g., poverty, high crime rates), disadvantaged school setting, and negative peer influences.
Treatment for Conduct Disorder
There are a variety of treatment approaches for conduct disorder, but only a few have been empirically supported. Treatments that are considered efficacious or promising are categorized into family-based, individual-based, community-based, and multicomponent interventions. Goals are to decrease conduct-disordered behaviors and to improve prosocial functioning of the individual as well as to improve family and parent interactions.
Because family dysfunction is considered to be one of the major contributors to delinquent behavior, treatment approaches have focused on family-based treatment. A specific type of family-focused intervention is functional family therapy (FFT). FFT is an integrative approach incorporating family systems; it considers the family as the system that is responsible for problematic behaviors rather than the individual alone. It also views the child as a part of multiple systems, including the community, school, and peer group. It involves family, behavioral, and cognitive approaches. FFT conceptualizes problem behavior as a function of the family system and identifies how the family system displays problematic behaviors. The goal of treatment is to improve family communication and interaction patterns; counselors using FFT teach problem-solving techniques in order to improve sup-portiveness in the family environment.
Parent management training (PMT) is one of the most effective and widely used treatments for conduct disorders. There are a variety of models that are behavioral in nature and focus on training parents to alter ineffective or inconsistent discipline strategies in order to change the child’s behavior at home. Therapists work with parents to develop and implement behavior management techniques such as positive reinforcement and contingency management in order to decrease negative behavior and increase compliance. Therapy also teaches parents to identify behaviors and use strategic principles to manage behaviors, and it provides an opportunity to practice using these techniques. Therapy also improves the parent-child interaction and reduces deviant and oppositional behaviors. PMT has been found effective for children from 6 to 12 years of age.
Pharmacological interventions have been used in treating attention deficit and disruptive behavior disorders and other mental health problems in children and adolescents. Although stimulant medication for ADHD is widely supported and effective, research for psychopharmacological treatment for conduct disorder alone has not been established. Pharmacological treatment should be considered when there is comorbidity with conduct disorder.
Child-focused interventions include cognitive-behavioral therapy (CBT) approaches. CBT is a treatment model that considers and involves cognitions, affect, and behavior when treating childhood disorders. The goal of CBT is to teach coping skills, build upon strengths, provide opportunities for practicing new behaviors, and provide interventions. Examples of CBT interventions that have shown promising effects are anger management and emotion regulation, relaxation training, problem-solving skills, cognitive restructuring, and social skills training.
A specific CBT treatment program for conduct disorder is social problem-solving skills training (PSST). PSST teaches cognitive problem-solving skills in order to address the cognitive deficits in processing associated with conduct-disordered individuals. New ways to perceive and process situations are also developed through the use of role-plays and homework assignments. In PSST, the therapist teaches the client new interpersonal and problem-solving skills such as exploring how situations are perceived and brainstorming ideas to engage in alternative behaviors. PSST has been shown to reduce symptoms of aggressive and antisocial behaviors in older children or adolescents.
Community programs address problems from a family systems perspective or incorporate individualized treatment with family therapy. Interventions include those that occur in the community, in places where the treatment occurs (i.e., hospital or correctional facility), and in the school, the home, and with peers. Residential treatment, group homes, and foster care placements are community-based centers that also provide various treatments for conduct disorders.
Multimodal interventions combine one or more of the above-mentioned interventions for the treatment of psychological disorders, including conduct disorders. Researchers have evaluated the effectiveness of the combination of PMT and PSST skills-based training, and results showed that a combined treatment led to changes in child and parent functioning up to 1 year after treatment. After 15 to 20 sessions, children between the ages of 7 and 13 were less aggressive and exhibited fewer externalizing behaviors.
Multisystemic therapy (MST) is another example of a multimodal intervention that has been empirically validated for treatment of serious conduct disorders. MST is based on family systems and community based theories and incorporates a milieu of different disciplines and systems in which the child is involved (community, peers, and school). MST views the family as the main focus of intervention, and therapists often work intensively with the family in their home environment. The goal is to provide parents with techniques to manage their children’s behavior and provide the children with strategies for coping with their problems. MST has been associated with reducing an individual’s re-arrest rate, criminal activity, and other serious offenses.
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