Conduct disorder (CD) is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition/text revision (DSM-IV-TR), as a repetitive and persistent pattern of behavior that violates the rights of others or violates major age-appropriate societal norms or rules. These behaviors fall into four main categories: (1) aggressive conduct that threatens physical harm to people or animals, (2) nonaggressive conduct that causes property loss or damage, (3) deceitfulness and theft, and (4) serious violations of rules. DSM-IVTR also makes the distinction between children who begin showing severe antisocial and aggressive behaviors before age 10 (i.e., childhood onset) and those who do not show severe conduct problems before age 10 (i.e., adolescent onset).
Research on the development of conduct problems has uncovered a large number of risk factors associated with CD. These risk factors include dispositional characteristics located within the child (e.g., biological abnormalities, predisposing personality traits, cognitive deficits), as well as factors involving the child’s social context (e.g., dysfunctional parenting practices, peer rejection, impoverished living conditions). Research suggests that risk factors have a cumulative effect on the development of problem behavior, with risk increasing in a linear manner from the presence of no risk factors to the presence of six or more risk factors.
Research has also suggested that not all children with CD develop their behavioral problems due to the same causal factors. For example, children in the childhood-onset group are characterized by a number of dispositional risk factors such as difficult temperament, impulsivity, low intelligence, and other cognitive deficits that act to exacerbate existing contextual risk factors (e.g., family dysfunction, impoverished living conditions) to place them at a greater risk for later maladjustment. Recent research also suggests that childhood-onset children can be further divided into (a) those who show a deficit in conscience development and are characterized by a callous and unemotional interpersonal style and (b) those who show very impulsive and emotionally dysregulated behaviors without a callous and unemotional style.
In contrast, youth in the adolescent-onset subgroup do not consistently show these risk factors. The conduct problems of adolescent-onset children are thought to be an exaggeration of the normative developmental process of identity formation that takes place in adolescence. If they do differ from other children, it seems primarily to be in showing greater affiliation with delinquent peers and scoring higher on measures of rebelliousness and authority conflict. The distinction between childhood-onset and adolescent onset trajectories to CD is a very influential model for explaining the different pathways through which children may develop severe conduct problems. However, it is important to note that clear differences between children in the two pathways are not always found, and the applicability of this model to girls requires further testing.
Reviews of the treatment outcome literature have documented four treatments with proven effectiveness for reducing conduct problems in youth: (1) contingency management programs, (2) parent management training (PMT), (3) cognitive-behavioral programs, and (4) use of stimulant medication. Although each of these four interventions has proven to be effective in reducing conduct problems, even these treatments have a number of substantial limitations. These limitations have led researchers to propose the use of comprehensive and individualized treatments that take into account the different developmental pathways that children with CD have been shown to follow. Recognizing these developmental pathways can aid the clinician in determining which causal processes may be involved in the development of CD for a particular child and can guide decisions as to the most important targets of interventions. Furthermore, knowledge of the developmental course of CD allows for the implementation of interventions as early as possible in the developmental sequence.
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