# Evidence-based assessment/Conduct disorder/ Extended version

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## What is a "portfolio"?

* For background information on what assessment portfolios are, click the link in the heading above.
* Does this all feel like too much information? There's a condensed version of this page here.

## Preparation phase
### Diagnostic criteria for Conduct disorder

   ICD-11 Diagnostic Criteria
   Conduct-dissocial disorder is characterized by a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms, rules, or laws are violated such as aggression towards people or animals; destruction of property; deceitfulness or theft; and serious violations of rules. The behaviour pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. To be diagnosed, the behaviour pattern must be enduring over a significant period of time (e.g., 12 months or more). Isolated dissocial or criminal acts are thus not in themselves grounds for the diagnosis.
   Note: The ICD-11 lists 8 additional subcategories of conduct-dissocial disorder. They can be found here.
   Changes in DSM-5
   * The diagnostic criteria for Conduct disorder changed slightly from DSM-IV to DSM-5. Summaries are available here.

### Base rates of conduct disorder in different clinical settings and populations

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of conduct disorder that they are likely to see in their clinical practice.
* To see prevalence rates across multiple disorders, click here.
| Demography | Setting | Base Rate | Diagnostic Method |
| All of U.S.A. | Nationally representative large-scale study (N=9282) - adult retrospective report | 9.5% overall: 12% males, 7% females | CIDI: WHO Composite International Diagnostic Interview (Parent Interview) |
| Western North Carolina | The Great Smoky Mountains Study – longitudinal, population-based study of community sample | 9.0% overall: 14% males, 4% females | CAPA: Child and Adolescent Psychiatric Interview (Parent and Youth Interview) |
| California, Division of Juvenile Justice (DJJ) | Incarcerated adolescents | 93% males, 92% females | SCID-IV: Structured Clinical Interview for DSM-IV (Youth Interview) |
| All of USA | National Comorbidity Survey Replication Adolescent Supplement –population-based study of adolescents | 5.4% Overall | CIDI (Parent Interview) |
| Various locations across USA | Community samples – summary of past findings | 6-16% males, 2-9% females | Varied |
| Urban Midwestern USA | Clinic-referred sample | 12.5% overall; 50% of those with CD met criteria for CU traits based on combined-informant report on APSD | KSADS-PL |
| Small metropolitan area in SE USA | Community based sample | 16.2% overall; 32% of those with CD met criteria for CU traits based on combined-informant report on APSD | CSI-4, based on combined-informant report |
Note: Despite a plethora of studies assessing prevalence of comorbidity of conduct disorder with other disorders (e.g., substance abuse, bipolar, ADHD), searches outlined below did not yield a single study providing a prevalence of conduct disorder alone in an outpatient or community clinic setting.

## Prediction phase
### Diagnostic strategy

The current strategy of diagnosis for Conduct Disorder is the Multistage Strategy for Evidence-Based Assessment of Conduct Disorder.
   Stage 1:
   The first stage of diagnosis uses any of the following evidence based assessments: Achenbach System of Empirically Based Assessments (ASEBA): Child Behavior Checklist (CBCL), Teacher Report Form (TRF), Youth Self-Report (YSR). These are used to broadly identify behaviors relevant to conduct disorder as outlined by the DSM. Both the Inventory of Callous Unemotional Traits and the Antisocial Process Screening Device (APSD) is assess whether child or adolescent is displaying callous and unemotional (CU) traits, a recently added symptom of conduct disorder as outlined by the DSM-5. There are multiple assessments taken by informants due to the covert nature of many conduct disorder problems.
   Stage 2:
   The second stage of diagnosis involves interviews with the patient. The Structured Diagnostic Interview (KSADS) is used to assess the potential comorbidity of conduct disorders. A semi-structured diagnostic interview (KSADS) is recommended due to its flexibility. The tool has been shown to gain client-specific information vital for case conceptualization and treatment planning, including clear descriptions of the child's behavior, peer relationships, and social skills. It also helps assess comorbidity. Age of onset of conduct problems is established in this phase, which helps determine developmental pathways.
   Part of this stage of diagnosis also involves standardized intelligence tests and academic achievement screeners. Developmental and medical history is also obtained through clinical interviews. For children, clinicians may utilize observational analogues, including parent-child interactions through child's games, parent's games, and clean up. Parents will also submit a parent daily report for observation measures. Clinicians utilize this data to assess the level of functional impairment or adaptive disability according to scales such as the Child and Adolescent Functional Assessment Scale
   Stage 3:
   The third stage of diagnosis examines the patient's broader social and environmental context through Neighborhood Questionnaire, Community Interaction Checklist, and "Things I Have Seen and Heard" interviews. Assessment of social informational processing could yield important information relevant to the “three P’s”. Social information processing can be tested through an Intention-Cue Detection Task. It is also important to assess for familial risk factors through an antisocial behavior checklist. Further assessments specific to the symptomatology of the child or adolescent also should be conducted through assessments.
   Covert conduct problem behaviors are difficult to assess, and the clinical utility of some innovative observational paradigms needs to be demonstrated. Research points to the “recent proliferation of research concerning girls and CP and suggest that this “should facilitate the development of evidence-based guidelines that are applicable to girls in the near future.” For the time being, they recommend following the same guidelines for girls as for boys, with the addition of a measure of relational aggression in girls.

### Psychometric properties of screening instruments for Conduct disorder

The following section contains a list of screening and diagnostic instruments for Conduct disorder. The section includes administration information, psychometric data, and PDFs or links to the screenings.
* Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
* For a list of more broadly reaching screening instruments, click here.

### Semi-structured and Structured Diagnostic Interviews

| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Inter-rater reliability | Test-retest reliability | Construct validity | Content validity |
| DICA (Diagnostic Interview for Children and Adolescents) | | 6-18 | | G | G | E | E |
| DISC (Diagnostic Interview Schedule for Children) | general population/ clinican | 4-12 | 70/ 90-120 | G | G | E | E |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Likelihood ratios and AUCs of screening measures for Conduct disorder

The following section contains a list of likelihood ratios and AUCs if screening measures for Conduct disorder. The section includes administration information, psychometric data, and PDFs or links to the screenings for children and adolescents.
* Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
* For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
| Screening Measure "(Primary Reference)" | Area under curve (AUC) and Sample Size | LR+ "(Score)" | LR- "(Score)" |
| Children and Adolescents (6-18 Years) ||||
| CBCL Rule-breaking T-Score | | | |
| CBCL Aggression T-Score | .80 (N=370) | 4.18 (55+) | .35 (<55) |
| Adolescents (12 to 18 years) ||||
| Antisocial Process Screening Device-Self-Report | .72 (N=250) | | |
| Antisocial Process Screening Device Self-Report** | | 1.56 (2+) | 74 (<2) |
| Inventory of Callous And Unemotional Traits | .65 (N=341) | 1.79 (26+) | .61 (<26) |
Note: “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes offormulation; The Kahn et al., 2012 paper used 4 items from the APSD that mapped onto the DSM-V “Limited Prosocial Emotions” specifier. Of these items , those that were scored as definitely true were rated as present and the presence of two of the four items met the specifier threshold
Searches (specified below) did not yield any data about sensitivity, specificity, AUC, or ROC for the Antisocial Process Screening Device, or for the Externalizing scale of the CBCL. Searches also did not yield data about TRF or YSR scales for Aggression or Externalizing: Achenbach and Rescorla (2001) provide data about clinically referred vs. non-referred samples but not about samples with conduct disorder specifically; thus, only AUC and LRs for the Aggression scale are reported. No studies were found that provide information about the likelihood of children or adolescents referred for conduct disorder receiving TRF or YSR Aggression or Externalizing scaled scores of a specific level versus non-CD youth receiving those scores.

### Interpreting Conduct disorder screening measure scores

* For information on interpreting screening measure scores, click here.
* Also see the page on likelihood ratios in diagnostic testing for more information

## Prescription phase
### Rating scales for conduct problems

| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Inter-rater reliability | Test-retest reliability | Construct validity | Content validity |
| ASEBA (Achenbach System of Empirically Based Assessment) not free | | 1:6-90+ | | A | E | E | G |
| BASC-2 (Behavior Assessment System for Children, 2nd Edition) not free | teacher/ parent/ self-report | 2:0-21:11 for parent/ teacher; 6:0-college age for self-report | 10-20 minutes for parent/ teacher; 30 minutes self-report | A | E | G | E |
| CASI-5 (Child Symptom Inventory for DSM-IV) not free | | | | A | A | G | E |
| ECBI/ SESBI-R (Eyberg Child Behavior Inventory/Sutter-Eyberg Child Behavior Inventory-Revised) not free | parent/ teacher | 2-16 | 5 minutes | A | A | E | E |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Observational Coding Systems

| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Inter-rater reliability | Test-retest reliability | Construct validity | Content validity |
| BCS (Behavioral Encoding System) | | | | A | U | G | A |
| DPICS (Dyadic Parent-Child Interaction Coding System) | observational | | | A | L | G | A |
| Compliance Test | | | | E | A | G | A |
| ASEBA-DOF (ASEBA Direct Observation Form) not free | observational | 6-11 | interval | G | G | E | E |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

## Process phase

The following section contains a brief overview of treatment options for Conduct disorder and list of process and outcome measures for Conduct disorder. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

### Process measures

See Table 1 in Section 1.1 for overview of evidence-based measures to use depending on etiology, symptomatology and conduct problems

### Outcome and severity measures

This table includes clinically significant benchmarks for Conduct disorder specific outcome measures
* Information on how to interpret this table can be found here.
* Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
* For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
   Statistically significant change benchmarks with common instruments
   | Measure | Subscale | Cut-off scores* | Cut-off scores* | Cut-off scores* | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
   | | | A | B | C | 95% | 90% | SE$_{difference}$ |
   | Benchmarks Based on Published Norms ||||||||
   | CBCL T-scores (2001 Norms) | Externalizing | 49 | 70 | 58 | 7 | 6 | 3.4 |
   | Conduct Disorder Samples Were Not Found in Searches* ||||||||
Note: “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean
Search terms: (1)“antisocial process screening device,” (2) antisocial process screening device AND benchmarks, searches previously mentioned.

## External Resources

See Effective Child Therapy, a website sponsored by The Society for Child and Adolescent Psychology (APA, Division 53) and the Association for Behavioral and Cognitive Therapies (ABCT), for current summary of evidence-based treatments.
* Antisocial personality disorder
* Bullying
* Oppositional defiant disorder
* Parental alienation
* Society of Clinical Child and Adolescent Psychology
* EffectiveChildTherapy.Org information on rule-breaking, defiance, and acting out