IACAPAP Textbook of Child and Adolescent Mental Health

EXTERNALISING DISORDERS

Chapter

D.3

CONDUCT DISORDERS
Stephen Scott

Stephen Scott BSc, FRCP,
FRCPsych
Professor of Child Health andBehaviour; Head, National
Specialist Conduct Problems
Clinic; Head, National Specialist
Adoption and Fostering Clinic& Director of Research,
National Academy for Parenting
Practitioners, London, UK
Conflict of interest: nonereported.

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
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©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Scott S. Conduct disorders. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva:
International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

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IACAPAP Textbook of Child and Adolescent Mental HealthThis section follows on from Chapter D.2, oppositional defiant disorder,
by focusing on conduct disorder, which tends to occur in older children
and teenagers.

CLASSIFICATION

ICD-10ICD-10 has a category for conduct disorders, F91. The clinical descriptions
and diagnostic guidelines state:“Examples of the behaviours on which the diagnosis is based
include the following: excessive levels of fighting or bullying;cruelty to animals or other people; severe destructiveness toproperty; firesetting; stealing; repeated lying; truancy from schooland running away from home; unusually frequent and severe
temper tantrums; defiant provocative behaviour; and persistentsevere disobedience. Any one of these categories, if marked, issufficient for the diagnosis, but isolated dissocial acts are not.”(p267)
An enduring pattern of behaviour should be present, but no time frame is given
and there is no impairment or impact criterion stated.
The ICD-10 diagnostic criteria for research differ, requiring symptoms tohave been present for at least 6 months, and the introductory rubric indicatesthat impact upon others (in terms of violation of their basic rights), but not
impairment of the child, can contribute to the diagnosis. The research criteria
take a menu-driven approach whereby a certain number of symptoms have to bepresent. 15 behaviours are listed to consider for the diagnosis of conduct disorder,
which usually but not exclusively apply to older children and teenagers. They canbe grouped into four classes:•

Aggression to people and animals
−
−
−
−
−
−

•

Destruction of property−−•

Often lies or breaks promises to obtain goods or favours or to avoid
obligations
Frequently initiates physical fights (this does not include fights withsiblings)
Has used a weapon that can cause serious physical harm to others (e.g.,bat, brick, broken bottle, knife, gun)Often stays out after dark despite parenting prohibition (beginningbefore 13 years of age)
Exhibits physical cruelty to other people (e.g., ties up, cuts or burns a
victim)Exhibits physical cruelty to animals.
Deliberately destroys the property of others (other than by fire-setting)
Deliberately sets fires with a risk or intention of causing serious damage).

Deceitfulness or theft−

Steals objects of non-trivial value without confronting the victim, either
within the home or outside (e.g. shoplifting, burglary, forgery).

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IACAPAP Textbook of Child and Adolescent Mental Health•

Serious violations of rules−

Is frequently truant from school, beginning before 13 years of age−

Has run away from parental or parental surrogate home at least twice or
has run away once for more than a single night (this does not include
leaving to avoid physical or sexual abuse)−Commits a crime involving confrontation with the victim (including
purse-snatching, extortion, mugging)−

Forces another person into sexual activity−

Frequently bullies others (e.g., deliberate infliction of pain or hurt,
including persistent−

Intimidation, tormenting, or molestation)−

Breaks into someone else’s house, building or car.

To make a diagnosis, three symptoms from this list have to be present,
one for at least six months. There is no impairment criterion. There are threesubtypes: conduct disorder confined to the family context (F91.0), unsocialised conductdisorder (F91.1, where the young person has no friends and is rejected by peers),
and socialised conduct disorder (F91.2, where peer relationships are normal). It is
recommended that age of onset be specified, with childhood onset type manifesting
before age 10, and adolescent onset type after. Severity should be categorised as mild,moderate, or severe according to number of symptoms or impact on others, e.g.,
causing severe physical injury; vandalism; theft.
Where there are sufficient symptoms of a comorbid disorder to meet
diagnostic criteria, the ICD-10 system discourages the application of a second
diagnosis, and instead offers single, combined categories. There are two major
kinds: mixed disorders of conduct and emotions, of which depressive conduct disorder(F92.0) is the best researched; and hyperkinetic conduct disorder (F90.1). There ismodest evidence to suggest these combined conditions may differ somewhat fromtheir constituent elements.
DSM-IVThe DSM IV-R system follows the ICD-10 research criteria very closely anddoes not have separate clinical guidelines. The same 15 behaviours are given forthe diagnosis of conduct disorder (312.8), with almost identical wording. As for
ICD-10, 3 symptoms need to be present for diagnosis. Severity, and childhood oradolescent onset are specified in the same way. However, unlike ICD-10, there isno division into socialised/unsocialised, or family context only types, and there is arequirement for the behaviour to cause clinically significant impairment in social,academic, or social functioning. Comorbidity in DSM IV-R is handled by giving
as many separate diagnoses as necessary, rather than by having single, combined
categories.
Differential diagnosis
Making a diagnosis of conduct disorder is usually straightforward but
comorbid conditions are often missed. The differential diagnosis may include:
Hyperkinetic syndrome/attention deficit hyperactivity disorder
These are the names given by ICD-10 and DSM IV-R respectively for

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IACAPAP Textbook of Child and Adolescent Mental Healthsimilar conditions, except that the former is more severe. For convenience
the term hyperactivity will be used here. It is characterised by impulsivity,
inattention, and motor overactivity. Any of these three sets of symptoms
can be misconstrued as antisocial, particularly impulsivity, which can also
be present in conduct disorder. However, none of the symptoms of conductdisorder are a part of hyperactivity so, excluding conduct disorder should
not be difficult. A frequently made error however, is to miss comorbid
hyperactivity when conduct disorder is definitely present. Standardised
questionnaires are very helpful here, such as the Strengths and Difficulties
Questionnaire, which is brief, and just as effective at detecting hyperactivity
as much longer alternatives.
Adjustment reaction to an external stressor
This can be diagnosed when onset occurs soon after exposure to an
identifiable psychosocial stressor such as divorce, bereavement, trauma,
abuse or adoption. The onset should be within one month for ICD-10, andthree months for DSM IV-R, and symptoms should not persist for morethan six months after the cessation of the stress or its sequelae.
Mood disorders
Depression can present with irritability and oppositional symptoms but,unlike typical conduct disorder, mood is usually clearly low and there arevegetative features; also more severe conduct problems are absent. Early
manic depressive disorder can be harder to distinguish, as there is often
considerable defiance and irritability combined with disregard for rules,
and behaviour which violates the rights of others. Low self-esteem is thenorm in conduct disorder, as is a lack of friends or constructive pastimes.
Therefore it is easy to overlook more pronounced depressive symptoms.
Systematic surveys reveal that around a third of children with conductdisorder have depressive or other emotional symptoms severe enough towarrant a diagnosis.
Autistic spectrum disorders
These are often accompanied by marked tantrums or destructiveness, which
may be the reason for seeking a referral. Enquiring about other symptoms
of autistic spectrum disorders should reveal their presence.
Dissocial/antisocial personality disorder
In ICD-10 it is suggested a person should be 17 or older before dissocial
personality is considered. Since at age 18 most diagnoses specific tochildhood and adolescence no longer apply, in practice there is seldom
difficulty. In DSM IV-R conduct disorder can be diagnosed over 18, so
there is potential overlap. A difference in emphasis is the severity andpervasiveness of the symptoms of those with personality disorder, whereby
all the individual’s relationships are affected by the behaviour pattern, andthe individual’s beliefs about his antisocial behaviour are characterised bycallousness and lack of remorse. Coexistent with conduct disorder there may
be the personality trait of psychopathy. The characteristics of the psychopath
include grandiosity, callousness, deceitfulness, shallow affect and lack ofremorse. These traits, as assessed by the Hare Psychopathy Checklist, have

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Can the “fledgling
psychopath” be identified inchildhood, as a high priority
target for prevention?
Callous unemotional
traits such as lack of guilt,
absence of empathy,
and shallow, constricted
emotions can be observedin children.

4IACAPAP Textbook of Child and Adolescent Mental Healthbeen shown to predict which individuals will engage in the most serious
and violent crime careers. Can the “fledgling psychopath” be identified inchildhood, as a high priority target for prevention? Callous unemotional
traits such as lack of guilt, absence of empathy, and shallow, constricted
emotions can be observed in children. A number of reliable instruments are
now available for the clinical assessment and diagnosis of psychopathic traits
in juvenile patients (Salekin & Lynam, 2010).
Subcultural devianceSome youths are antisocial and commit crimes but are not particularly
aggressive or defiant. They are well adjusted within a deviant peer culturethat approves of recreational drug use, shoplifting, etc. In some localities
a third or more teenage males fit this description and would meet ICD10 diagnostic guidelines for socialised conduct disorder. Some clinicians
are unhappy to label such a large proportion of the population with a
psychiatric disorder. Using DSM IV-R criteria would preclude the diagnosis
for most youths like this due to the requirement for significant impairment.
Multiaxial assessment
ICD-10 recommends that multiaxial assessment be carried out for children
and adolescents, while DSM IV-R suggests it for all ages. In both systems, axis one
is used for psychiatric disorders, which have been discussed above. The last threeaxes in both systems cover general medical conditions, psychosocial problems, andlevel of social functioning respectively; these topics will be alluded to below underaetiology. In the middle are two axes in ICD-10, which cover specific (Axis two)and general (Axis three) learning disabilities respectively; and one in DSM IV-R
(Axis two) which covers personality disorders and general learning disabilities.

Conduct disordered children often become
involved in physical fights.
Photo: Tony Fischer

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IACAPAP Textbook of Child and Adolescent Mental Health

Both specific and general learning disabilities are essential to assess inindividuals with conduct problems. Fully a third of children with conduct disorderalso have specific reading retardation, defined as having a reading level two standard
deviations below that predicted by the person’s IQ (see also Chapter C.3). While
this may in part be due to lack of adequate schooling, there is good evidence thatthe cognitive deficits often precede the behavioural problems. General learning
disability (mental retardation) is often missed in children with conduct disorderunless IQ testing is carried out. The rate of conduct disorder rise several-fold as IQ
gets below 70.

EPIDEMIOLOGY
Between 2% and 8% of children and adolescents have conduct disorders.
With respect to historical period, A modest rise in diagnosable conduct disorder
over the second half of the twentieth century has also been observed comparing
assessments of three successive birth cohorts in Britain. There is a marked social
class gradient. With respect to ethnicity, youth self-reports of antisocial behaviours
and crime victim survey reports of perpetrators’ ethnicity show an excess ofoffenders of black African ancestry. Importantly, Hispanic Americans in the USA
and British Asians in the UK do not tend to show an excess of offending comparedto their white counterparts, indeed the latter have lower rates than the native white
population.
Gender
The sex ratio is approximately 4 to10 males for each female overall, withmales further exceeding females in the frequency and severity of behaviours. Onbalance, research suggests that the causes of conduct problems are the same forboth sexes, but males have more conduct disorder because they experience moreof its individual-level risk factors (e.g., hyperactivity, neuro-developmental delays).
However, recent years have seen concern among clinicians about increasingly
treating antisocial behaviour among girls.

Click on the picture toaccess the UK Independent
Commission on Youth Crime
and Antisocial Behaviour’2010 report Time for a freshStart.

Developmental subtypes
Life-course persistent versus adolescence-limited
There has been considerable attention paid to the distinction between
aggressive and disruptive behaviors that are first seen in early childhood versus
those that start in adolescence (Moffitt, 1993a; Patterson & Yoerger, 1993), andthese two subtypes are encoded in the DSM-IV diagnostic system for conductdisorder. Early onset is a strong predictor of persistence through childhood– and early onset delinquency is more likely to persist into adult life. Findings
from the longitudinal Dunedin study, following a 1972-73 birth cohort, haveshown that those with early onset differ from those with later onset in that they
have lower IQ, more attentional and impulsivity problems, poorer scores onneuropsychological tests, greater peer difficulties and are more likely to comefrom adverse family circumstances (Moffitt et al, 2001). Those with later onset,
by contrast are thought to become delinquent predominantly as a result of social
influences such as association with other delinquent youths, or seeking social statusthrough delinquent behaviors. Moffitt (1993a) termed the early-onset group “lifeConduct disorders

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IACAPAP Textbook of Child and Adolescent Mental Healthcourse persistent”, and the later-onset group “adolescence-limited” thus linking
developmental course to the differences in underlying deficits. The distinction
between the two groups has been broadly supported in longitudinal studies ofseveral cohorts from a dozen countries (Moffitt, 2006). Findings from the follow
up of the Dunedin cohort support relatively poorer adult outcomes for the earlyonset group in the domains of violence, mental health, substance abuse, work andfamily life (Moffitt et al, 2002). Follow-up to age 32 revealed that the early-onset
life course persistent group had compromised physical health relative to othercohort men, as shown by increased injuries, primary-care physician and hospital
visits, and clinical tests of sexually transmitted infections, systemic inflammation,
periodontal disease, decayed teeth, and chronic bronchitis.
However the ‘adolescence-limited’ group were not without adult difficulties(Moffitt et al, 2002). As adults they still engaged in self-reported offending, andalso had problems with alcohol and drugs. The Cambridge Study in Delinquent
Development, a longitudinal study of 411 London males from age 8 to 46, also
found that those with antisocial behaviors starting in adolescence were likely
to continue to commit undetected crimes in adult life, although their work
performance and close relationships were not impaired (McGee & Farrington,2010). Thus, the age-of-onset subtype distinction has strong predictive validity, butadolescent-onset anti-social behaviors may have more long-lasting consequences
than previously supposed and thus both, childhood-onset and adolescent-onset
conduct problems, warrant clinical attention.
Childhood-limited conduct problems
Robins (1966) first pointed out that one half of conduct-problem children
do not grow up to have antisocial personalities. Longitudinal studies aiming to
document the continuity of antisocial behavior from childhood to adolescence
to adulthood have repeatedly revealed the existence of an exceptional group ofchildren who lack such continuity. These are often termed “childhood-limited”
conduct problems (Moffitt, 2006). Some studies define this childhood-limitedgroup broadly (as a large group of children having any elevated disruptive
behavior), and these draw our attention to the ubiquity of temporary conduct
problems in the healthy population of children, and show that so long as mild
conduct problems do not persist they need not portend poor prognosis (Tremblay,
2003). In contrast, other studies define this childhood-limited group morenarrowly (as a small group of children exhibiting extreme, pervasive, and persistentantisocial behavior problems only during childhood). These studies report thatsuch childhood-limited antisocial boys develop into adult men who are depressed,
anxious, socially isolated, and have low-paid jobs (Farrington et al, 1988; Moffitt
et al, 2002). Thus, boys whose conduct problems are severe and persistent enoughto warrant a clinical diagnosis may not later develop antisocial personality, butthey will suffer other forms of maladjustment as adults. Thus, all conduct-disorderchildren warrant clinical attention.

Lee N Robins (19222009) made a significant
contribution to theunderstanding of the natural
history of conduct disorderin her seminal book DeviantChildren Grown Up.

When a young child presents for assessment, the clinician’s task is to makea differential diagnosis between childhood-onset CD that will be only childhoodlimited, versus childhood-onset CD that will in future have a life-course persistentcourse and pathological prognosis. DSM-IV’s age of onset distinction cannot
help with this task because all child patients, by definition, have childhood onset.

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IACAPAP Textbook of Child and Adolescent Mental HealthResearchers have tried to distinguish life-course persistent versus childhoodlimited trajectory groups by using childhood risk factors, without much success(Moffitt, 2006). However, initial evidence indicates that comorbid ADHD, as
well as family psychiatric history, characterize the persistent subtype, but not thechildhood-limited subtype.

AETIOLOGY
Individual-level characteristics
Genotypes
The search for specific genetic polymorphisms associated with conduct
problems is a very new scientific initiative and little has yet been accomplished. One
genome-wide linkage study has identified chromosomal regions that are good bets
for harbouring conduct problem-related polymorphisms, but the polymorphisms
have not been specified and the regions have not been replicated (Stallings et al,2005). The most-studied candidate gene in relation to conduct problems is the
MAOA promoter polymorphism. The gene encodes the MAOA enzyme, whichmetabolizes neurotransmitters linked to aggressive behavior by previous researchin mice, and among men in a Dutch family pedigree. Thus, MAOA was selected as
the candidate gene to test a hypothesis that genetic vulnerability might moderate
the effect of child maltreatment on later conduct problems in the cycle of violence(Caspi et al, 2002). Maltreatment history and genotype interacted to predict four
different measures of antisocial outcome: diagnosed adolescent conduct disorder,
a personality assessment of aggression, symptoms of adult antisocial personality
disorder reported by informants who knew the study member well, and adult court
conviction for violent crime. Replication of this study was of utmost importancebecause reports of associations between measured genes and disorders are notorious
for their poor replication record. Positive and negative replication studies haveappeared and a meta-analysis of these studies showed the association between
MAOA genotype and conduct problems is modest but statistically significant(Kim-Cohen et al, 2006). Findings of specific genetic polymorphisms associatedwith antisocial behavior will probably not be applied for genetic diagnosis purposes
because of the inherent complexity of gene-behavior connections. Rather, geneenvironment research will benefit efforts to understand how brain mechanisms
connect external risk factors and genomic variation to the conduct disorders(Meyer-Lindenberg et al. 2006).
Perinatal complications
Birth complications might be a contributory factor to neuropsychologicaldeficits that are associated with conduct problems (Moffitt, 1993). The evidence
regarding this was mixed but recent reports from large-scale general population
studies have found associations between life-course persistent type conduct
problems and perinatal complications, minor physical anomalies, and low birthweight (Brennan et al, 2003). Most studies support a biosocial model in which
obstetric complications might confer vulnerability to other co-ocurring risks suchas hostile or inconsistent parenting (Arseneault et al, 2002; Kratzer & Hodgins,
1999; Tibbetts & Piquero, 1999; Raine et al, 1997). Studies have further indicatedthat smoking in pregnancy increases the risk of conduct problems in the offspring(Brennan et al, 2003), but a causal link between smoking and conduct problems
has not been established (Fergusson, 1999).

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8IACAPAP Textbook of Child and Adolescent Mental HealthTemperament
Individual differences in infancy that might contribute to subsequentrisk of psychopathology were conceptualised by Thomas and Chess in terms of“temperament”, which they viewed as inherited and not significantly influenced
by experience (Thomas et al, 1968). Several prospective studies have shownassociations between temperament and conduct problems (Keenan & Shaw,2003), and also predicted antisocial personality disorder and criminal offending
into adulthood (Caspi et al, 1996). Temperament as originally conceived, should
be strongly heritable and experience-free. However measures of temperament are
only moderately heritable and a child’s engagement with the social world frombirth means that temperament measures inevitably assess the outcome of social
processes. It may be that the contributions of temperament will be seen mostconsistently in combination with environmental risk factors (Nigg, 2006).
Neurotransmitters
Neurotransmitters have been linked to antisocial behavior in adult samples
and in non-human animal models (Nelson, 2006). It would be a major advance if
it were possible to link neurotransmitter levels and activity to conduct problems
in children. However, in general, the findings with children have not been
consistent (Hill, 2002). For example, in the Pittsburgh Youth cohort, boys withlongstanding conduct problems showed downward changes in urinary epinephrine
level following a stressful challenge task, whereas prosocial boys showed upward
epinephrine responses to the challenge (McBurnett et al. 2005). However otherstudies have failed to find an association between conduct disorder and measuresof noradrenaline in children (Hill, 2002). Some limited evidence supports theview that, as in adults, serotonin is linked with aggression in children, but findings
for indices of serotonin function in children are also markedly inconsistent (Pineet al, 1997). It should be borne in mind that neurotransmitters in the brain are
only indirectly measured – most measures of neurotransmitter levels are crude
indicators of activity – and little is known about neurotransmitters in the juvenile
brain.

To access the US Surgeon
Generals’ thorough report on
youth violence, click on the
picture.

Verbal deficits
Children with conduct problems have been shown consistently to haveincreased rates of deficits in language-based verbal skills (Lynam & Henry, 2001;
Nigg et al, 2003). Conduct disordered children, delinquent adolescents, and adultantisocial individuals show poor performance on standardised tests of verbal ability
and in tests of IQ, with poor verbal and performance scores. These associations
hold after controlling for potential confounds such as race, socioeconomic status,
academic attainment, and test motivation (Lynamet al, 1993). Longitudinalstudies show that persistence in antisocial behavior over periods of years ispredicted by low verbal IQ in childhood (Farrington & Hawkins, 1991; Lahey etal, 1995; Lynam & Henry, 2001). Deficits in verbal capacities are found also with
oppositional defiant disorder among preschool-aged clinic-referred boys (Speltz
et al, 1999). Several possible ways in which poor verbal ability might influence
behavior can be drawn from Luria’s theory of the role of verbal memory and verbal
abstract reasoning in the development of self-control (Luria, 1961). The abilities
to recall oral instructions and to use language to think through the consequences ofactions contribute to the effective control of actions. Children who cannot reason

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9IACAPAP Textbook of Child and Adolescent Mental Healthor assert themselves verbally may attempt to gain control of social exchanges using
aggression (Dodge, 1993). It is likely that there are also indirect effects in which
low verbal IQ contributes to academic difficulties, which in turn mean that thechild’s experience of school becomes unrewarding rather than a source of selfesteem and support.
Executive dysfunction
Children and adolescents with conduct problems have been shownconsistently to have poor tested executive functions (Ishikawa & Raine, 2003;
Lynam & Henry, 2001; Moffitt 1993b; Nigg & Huang-Pollock, 2003; Hobson etal, 2011). Executive functions comprise those abilities implicated in successfully
achieving goals through appropriate, effective actions. Specific skills include
learning and applying contingency rules, abstract reasoning, problem solving, selfmonitoring, sustained attention and concentration, relating previous actions tofuture goals, and inhibiting inappropriate responses. These mental functions arelargely, although not exclusively, associated with the frontal lobes (Pennington &Ozonoff, 1996). Important data was generated from a Montreal cohort studied
from the age of six years (Séguin et al, 1999). The study used executive function
tests, which have been shown to be associated with different anatomical structuresin the brain, on the basis of lesion and functional imaging studies. Chronic
aggression was associated with lower scores on tests tapping executive functions of
the frontal brain region, and the findings held after controlling for general memory,
IQ, and ADHD. Although most studies of executive deficits involve adolescents,
such deficits have also been linked with disruptive behaviors in preschool children(Hughes et al, 1998; Speltz et al, 1999).

Executive functions
The term “executivefunctions” is used todescribe cognitive
processes that activate,organize, integrate andmanage other functions
such as planning, problem
solving, verbal reasoning,inhibition, mental flexibility
and multi-tasking.

Information processing & social cognition
Dodge (1993) proposed the leading information-processing model for thegenesis of aggressive behaviours within social interactions. The model hypothesisesthat children who are prone to aggression focus on threatening aspects of others’
actions, interpret hostile intent in the neutral actions of others, and are more likely
to select and to favour aggressive solution to social challenges. Several studies
have demonstrated that aggressive children make such errors of social cognition.
An extensive review of the many studies of social cognitions among conductproblem children has been presented elsewhere. Dodge (1993) hypothesisedthat the tendencies to encode hostile aspects of situation and to attribute hostile
intent to ambiguous social cues and to access and favour aggressive responses tosocial challenges are the result of repeated exposure to physical maltreatment.
This prediction was tested prospectively (Dodge et al,1995). Physical abusedocumented in kindergarten was strongly associated with conduct problems inprimary school; 28% of the abused group developed conduct problems comparedwith 6% of the non-abused. Encoding errors, hostile attributions, and biases
toward accessing and favouring aggressive responses were each associated with
conduct problem outcome and with having experienced physical abuse. Encoding
errors and accessing aggressive responses mediated the link between physicalabuse and conduct problems, but hostile attributions and positive evaluation of
aggressive responses did not. This prospective study thus provided some support
for the social cognition model.

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Adolescents with conductdisorder are responsible for alarge part of the crime in mostcommunities.

Risks within the family
Genetic liability
There is now solid evidence from twin and adoption studies that conduct
problems assessed both dimensionally and categorically are substantially heritable(Moffitt, 2005a; Rhee & Waldman, 2002). However, knowing that conduct
problems are under some genetic influence is less useful clinically than knowing that
this genetic influence appears to be reduced, or enhanced, depending on interaction
with circumstances in the child’s environment. Several genetically sensitive studies
have allowed interactions between family genetic liability and rearing environment
to be examined. Adoption studies have reported an interaction between antisocial
behavior in the biological parent and adverse conditions in the adoptive home thatpredicted the adopted child’s antisocial outcome (Bohman 1996; Cadoret et al,1995). The genetic risk was modified by the rearing environment. A twin study
also yielded evidence that family genetic liability and environmental risks interact(Jaffee et al, 2005). In this study, the experience of maltreatment was associatedwith an increase of 24% in the probability of diagnosable conduct disorderamong children at high genetic risk, but an increase of only 2% among children
at low genetic risk. Thus, awareness of a familial liability toward psychopathology
increases the urgency to intervene to improve a child’s social environment.
Low income
There is an association between severe poverty and early-childhood conduct
problems (Murray & Farrington, 2010). Early theories proposed direct effects ofpoverty related to strains arising from the gap between aspirations and realities andfrom lacking opportunity to acquire social status and prestige. Subsequent research
has indicated that the association between low income and childhood conduct
problems is indirect, mediated via family processes such as marital discord andparenting deficits (Maughan, 2001). As one example of this research, the Iowa
longitudinal study of 378 rural families found that family economic stress was
associated with adolescent conduct problems, but this was mediated via parental
depression, marital conflict and parental hostility (Conger et al, 994). Anotherstudy took advantage of a naturally occurring experiment (Costello et al, 2003).
Native American families in North Carolina, formerly living below the poverty line,

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IACAPAP Textbook of Child and Adolescent Mental Healthbenefited from increased income from newly opened casinos. In many families,
the children’s behavior problems decreased markedly as a result. However, theeffect of increased income was mediated through better parent-child relationships.
This mediation is not limited to poverty in recent times. The Glueck’s study ofdelinquency from the historical period of economic depression also found thatharsh discipline, low supervision, and weak parent-child attachments accounted
for the effects of poverty on children’s antisocial behaviors in the 1930’s (Sampson& Laub, 1984).
Parent-child attachment
Early studies of low-risk samples, using the secure-insecure attachmentclassification, failed to find robust associations with externalising problems, but
subsequent studies of higher-risk samples using the disorganised classification
report that disorganised attachment can predict conduct problems (Van Ijzendorn
et al, 1999). Disorganisation is identified in Ainsworth’s Strange Situation Test if
the child shows bizarre or contradictory behaviors with the caregiver when reunited
after separation (Main & Solomon, 1986). However, low rates of infants withdisorganized attachment in study samples mean that findings should be viewed
with caution. Although it seems obvious that poor parent-child relations ingeneral predict conduct problems, it has yet to be established whether attachment
difficulties, as measured by observational paradigms, have an independent causal
role in the development of behavior problems. Attachment classifications could
be markers for other relevant family risks. However, Futh et al (2008) used a dollplay task with six-year-olds showing an independent association between insecureattachment and conduct problems and Scott et al (2011) found that in adolescentsinsecure attachment (measured using the Child Attachment Interview) predictedconduct problems even after taking into account current parenting quality,
suggesting it may have at least a maintaining role.
Discipline and parenting
Parents of conduct disordered children are more inconsistent in their useof rules, issue more and more unclear commands, are more likely to respond totheir children on the basis of their own mood rather than the characteristics ofthe child’s behavior, are less likely to monitor their children’s whereabouts, andare less responsive to their children’s prosocial behavior. Patterson proposed a
specific mechanism for the promotion of oppositional and aggressive behaviors
in children. A parent responds to mild oppositional behavior by a child with aprohibition, to which the child responds by escalating his behavior and mutual
escalation continues until the parent backs off, thus negatively reinforcing thechild’s behavior. The parent’s inconsistent behavior increases the likelihood of thechild showing further oppositional or aggressive behavior. In addition to specifictests of Patterson’s reinforcement model (Gardner, 1989; Snyder & Patterson,1995) there is ample evidence that conduct problems are associated with hostile,
critical, punitive and coercive parenting (Rutter et al, 1998); conduct disorderedchildren elicit more negative reactions from all groups of parents than non- conductdisorder children.

"All in all, the most marked
difference between thedisciplinary practicesof the parents of thedelinquents and thoseof the non-delinquents isfound in the considerably
greater extent to which theformer resorted to physicalpunishment and the lesser
extent to which theyreasoned with the boys
about their misconduct."(Glueck & Glueck, 1950)

The fact that children’s behaviors can evoke negative parenting does notmean that negative parenting has no impact on children’s behavior. One study
reported that negative maternal control at age four was significantly associatedConduct disorders

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IACAPAP Textbook of Child and Adolescent Mental Healthwith conduct problems at age nine, after controlling for children’s initial behavior
problems at age four (Campbell et al, 1996). The E-Risk longitudinal twin studyof British families examined the effects of fathers’ parenting on young children’s
aggression (Jaffee et al, 2003). As expected, a prosocial father’s absence predicted
more aggression by his children. But in contrast, an antisocial father’s presence
predicted more aggression by his children, and his harmful effect was exacerbatedthe more time each week he spent taking care of the children. In another report,
the E-risk study evaluated the hypothesis that because depressed mothers provide
inept parenting, maternal depression promotes children’s aggression (Kim-Cohenet al, 2005). Children of depressed mothers often develop conduct problems, but
it has not been clear that this correlation represents environmental transmission.
Although the connection between mothers’ depression and children’s conduct
problems decreased somewhat after stringent control for familial liability to
psychopathology, it remained statistically significant. Further, depressed womenmight exaggerate their ratings of their children’s problem behaviors, but the patternof findings remained the same when teachers rated the children’s behavior. A
temporal analysis showed that if E-risk mothers experienced depression only before
their children’s birth, the children were not unusually aggressive. In contrast, only
if mothers suffered depression while rearing their children were the children likely
to develop aggression. Finally, the possibility that the association was spurious
because children’s aggression provoked their mothers’ depression was ruled out by
documenting that children exposed to an episode of maternal depression between
ages five and seven became even more aggressive by age seven than they had been
at age five. Taken together these and other findings provide good evidence for therole of discipline in conduct problems (Moffitt, 2005b).

Click on the picture to accessthe University of Colorado
Blueprints for ViolencePrevention.

Exposure to adult marital conflict and domestic violence
It is likely that family processes other than parenting skills and quality ofparent-child attachment relationships have a role. Many studies have shown thatchildren exposed to domestic violence between adults are subsequently more likely
to themselves become aggressive (Moffitt & Caspi, 1998). Davies and Cummings(1994) proposed that marital conflict influences children’s behavior because of
its effect on their regulation of emotion. For example, a child may respond tofrightening emotions arising from marital conflict by down-regulating his own
emotions through denial of the situation. This in turn may lead to inaccurate
appraisal of other social situations and ineffective problem solving. Repeatedexposure to family conflict is thought to lower childrens’ thresholds for psychologicaldysregulation, resulting in greater behavioral reactivity to stress (Cummings &Davies, 2002). Children’s aggression may also be increased by marital discord
because children are likely to imitate aggressive behavior modelled by their parents(Bandura, 1977). Through parental aggression children may learn that aggression
is a normative part of family relationships, that it is an effective way of controllingothers, and that aggression is sanctioned, not punished (Osofsky, 1995).
Maltreatment
Physical punishment is widely used, and parents of children with conduct
problems frequently resort to it out of desperation. Links with conduct problems
are not however straightforward. One study found that physical punishment was
clearly associated with behavior problems in white American children, but not in
African-American ones (Deater-Deckard et al, 1996). Furthermore, the risk for

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IACAPAP Textbook of Child and Adolescent Mental Health

Birching (19th century Russia). Kaluga Art Museum.

conduct problems does not apply equally to all forms of physical punishment.
The E-risk longitudinal twin study was able to compare the effects of corporalpunishment (smacking, spanking) versus injurious physical maltreatment using
twin-specific reports of both experiences (Jaffee et al, 2004). Results showedthat children’s genetic endowment accounted for virtually all of the association
between their corporal punishment and their conduct problems. This indicated achild effect – in which children’s bad conduct provokes their parents to use more
corporal punishment, rather than the reverse. Findings about injurious physicalmaltreatment were the opposite. There was no child effect provoking maltreatment
and, moreover, significant effects of maltreatment on child aggression remained
after controlling for any genetic transmission of liability to aggression fromantisocial parents.
Overall, associations between physical abuse and conduct problems are wellestablished (Hill, 2002). In the Christchurch cohort, child sexual abuse predictedconduct problems after controlling for other childhood adversities (Ferguson etal, 1996). In a large prospective study of court-substantiated cases of abuse andneglect, 26% of abused and neglected adolescents were antisocial, contrasted
with 17% in a well-matched comparison group, implying a modest but longlasting effect of abuse and neglect (Widom, 1997). Investigating the relationshipof child maltreatment to psychopathology is particularly difficult for ethicalreasons. Little is known about the possible mechanisms linking maltreatment
to conduct problems, although threats to security of attachment, difficulties inaffect regulation, distortions of information processing and self-concept reviewed
elsewhere in this chapter are likely to be relevant.

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IACAPAP Textbook of Child and Adolescent Mental Health

Risks outside the family
Neighbourhood
It has long been assumed that bad neighbourhoods have the effect of
encouraging children to develop conduct problems. Parents strive to secure thebest neighbourhood and school for their child that they can afford. Although it isobvious that some local areas have higher crime rates than others, it has been difficult
to document any direct link between neighbourhood characteristics and childbehavior for a number of reasons. For example, neighbourhood characteristics wereconceptualized in overly simple structural-demographic terms, such as percentage
of non-white residents or percentage of single-parent households. Moreover,research designs could not rule out the alternative possibility that families whose
members are antisocial tend to selectively move into bad neighbourhoods. A newgeneration of neighbourhood research is addressing these challenges (Beyers etal, 2003; Caspi et al, 2000; Sampson et al, 1997). New research suggests thatthe neighbourhood factors that are important go beyond structural-demographic
characteristics. Neighbourhood-level social processes such as “collective efficacy”
and “social control,” do influence young children’s conduct problems, probably bysupporting or failing to support parents in their efforts to rear children.
Peers
Children with conduct problems have poorer peer relationships thannon-disordered children in that they tend to associate with children with similar
antisocial behaviors, they have discordant interactions with other children, andexperience rejection by non-deviant peers (Vitaro et al, 2001). Three principal
explanations have been tested and evidence found for all three. Either children’s
antisocial behaviors lead them to have peer problems or deviant peer relationships
lead to antisocial behaviours or some common factor leads to both.
Regarding the possibility that conduct problems lead to peer difficulties,
there is ample evidence that children with established conduct problems are more
likely to have more conflict with peers and to be rejected by non-deviant peers(Coie, 2004). This peer rejection has been shown to contribute to declines inacademic achievement and increases in aggression across the first year of primaryschooling (Coie, 2004). One consequence of rejection by healthy peers is that,from as young as five years of age, aggressive-antisocial children are obliged toassociate with other deviant children (Farver, 1996; Fergusson et al, 1999).
In light of the limited evidence that peer difficulties prompt the onsetof childhood conduct problems and the rather more substantial evidence thatchildren’s peer difficulties are a consequence of their conduct problems, is there
any reason to think that peer processes influence the long-term course of conduct
problems? Regarding the possibility that peers lead to conduct problems, this has
been shown to come about in several ways. Youth who are aggressive are attracted
to each other and deviant youth reinforce each others’ antisocial behaviors andattitudes (Boivin & Vitaro, 1995). Evidence that peer influences do increase
antisocial behaviors applies primarily to the adolescent developmental stage (Warr,
2002). Strong evidence comes from treatment experiments: in two controlled
clinical trials, boys treated in groups did worse than untreated controls; treatment
was followed by increased adolescent problem behaviors and poorer outcomes(Dishion et al, 1999). After group-level treatment brought the boys together they

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IACAPAP Textbook of Child and Adolescent Mental Healthmutually reinforced each other’s antisocial activities, a finding which argues forindividual treatment approaches. A natural-experiment study tracked change inantisocial behavior among boys who joined a gang to reveal that joining a gangincreased each adolescent’s individual offending over his pre-gang baseline, whereas
leaving the gang decreased each individual’s personal offending rate (Thornberry et
al, 1993). Overall, we must consider the dynamic and reciprocal manner in whichchildren’s conduct problems influence who their friends are and in which thosefriends later promote the young person’s conduct problems (Vitaro et al, 2001).
From risk predictor to evidence for causation
Associations have been documented above between conduct problems anda wide range of risk factors. A variable is called a risk factor if it has a documented
predictive relation with antisocial outcomes, whether or not the association iscausal. The causal status of most of these risk factors is unknown; we know what
statistically predicts conduct-problem outcomes but not how or why (Kraemer,
2003). Establishing a causal role for a risk factor is by no means straightforward,
particularly as it is unethical to experimentally expose healthy children to risk factors
to observe whether those factors can generate new conduct problems. There is noone solution to the problem, although the use of genetically sensitive designs andthe study of within-individual change in natural experiments and treatment studies
have considerable methodological advantages for suggesting causal influences on
conduct problems (Moffitt, 2005b; Rutter, 2000; Rutter et al, 2006). This chapter
has emphasized risk factors that have research evidence to support a causal rolein conduct problems. For example, above we have cited research that supports
causation by depressed mothers’ poor discipline (Kim-Cohen et al, 2005), childmaltreatment (Dodge et al, 1995; Jaffee et al, 2004), family poverty (Costello etal, 2003), familial genetic liability (Moffitt, 2005a), and affiliating with delinquent
peers (Dishion et al, 1999; Thornberry et al, 1993). These studies’ designs either
took advantage of natural experiments or otherwise were able to rule out alternative
explanations to causation (Moffitt, 2005b). Other risk factors described here havenot been decisively tested for causation yet but they do have evidence that they arerobust predictors of conduct problems across many studies carried out in different
contexts (e.g., perinatal complications, temperament, verbal and executive deficits,
slow heart rate, social cognitions, exposure to parental conflict). Still other risk
factors benefit from strong causal theory, warranting inclusion in this chapter, but
the evidence base to show reliable association with conduct problems is not yet
TABLE D.3.1 Factors predicting poor outcome
Onset

Early onset of severe problems, before age 8

Phenomenology

Antisocial acts which are severe, frequent, and varied

Comorbidity

Hyperactivity and attention problems

Intelligence

Lower IQ

Family History

Parental criminality; parental alcoholism

ParentingHarsh, inconsistent parenting with high criticism, low warmth, low involvement and low
supervision.

Wider environment

Low income family in poor neighbourhood with ineffective schools.

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IACAPAP Textbook of Child and Adolescent Mental Healthstrong (e.g., attachment, neurotransmitters, MAOA genotype, smoking during
pregnancy, neighbourhood context).

COURSE AND PROGNOSISOf those with early onset conduct disorder (before eight years of age) about
half persist with serious problems into adulthood. Of those with adolescent onset,
the great majority (over 85%) desist in their antisocial behaviour by their earlytwenties. Factors which predict poor outcome are shown in Table D.3.1.
To detect protective factors, children who do well despite adverse risk factors
have been studied. These so-called resilient children, however, have been shown tohave lower levels of risk factors, for example a boy with antisocial behaviour andlow IQ living in a rough neighbourhood but living with supportive, concerned
parents. Protective factors are mostly the opposite end of the spectrum of the samerisk factor, thus good parenting and high IQ are protective. Nonetheless there
are factors which are associated with resilience independent of known adverse
influences. These include a good relationship with at least one adult, who does
not necessarily have to be the parent; a sense of pride and self-esteem; and skills orcompetencies.
Adult outcome
Studies of groups of children with early onset conduct disorder indicate
a wide range of problems not only confined to antisocial acts, as shown in Table
D.3.2.
What is clear is that not only are there substantially increased rates ofantisocial acts in adulthood but that the general psychosocial functioning ofchildren with conduct disorder grown up is strikingly poor. For most of thecharacteristics shown in Table D.3.2, the increase compared to controls is at least
double for community cases who were never referred, and three to four times forreferred children.
Table D.3.2

Adult outcome

Antisocial Behaviour

More violent and non-violent crimes, e.g. mugging, grievous bodily harm; theft, car crimes,
fraud.

Psychiatric problems

Increased rates of antisocial personality, alcohol and drug abuse, anxiety, depression
and somatic complaints, episodes of deliberate self-harm and completed suicide, time inpsychiatric hospitals

Education andTraining

Poorer examination results, more truancy and early school leaving, fewer vocational
qualifications

Work

More unemployment, jobs held for shorter time, jobs low status and income, increased
claiming of benefits and welfare

Social network

Few if any significant friends, low involvement with relatives, neighbours, clubs andorganisations

Intimate
relationships

Increased rate of short lived, violent cohabiting relationships; partners often also antisocial

Children

Increased rates of child abuse, conduct problems in offspring, children taken into care

HealthMore medical problems, earlier death

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IACAPAP Textbook of Child and Adolescent Mental Health

Pathways
The path from childhood conduct disorder to poor adult outcome isneither inevitable nor linear. Different sets of influences impinge on the individual
growing up and shape the life course. Many of these can accentuate problems.
Thus a toddler with an irritable temperament and short attention span may notlearn good social skills if he is raised in a family lacking them and where he canonly get his way by behaving antisocially and grasping for what he needs. At
school he may fall in with a deviant crowd of peers, where violence and other
antisocial acts are talked up and give him a sense of esteem. His generally poor
academic ability and difficult behaviour in class may lead him to truant increasingly,
which in turn makes him fall further behind. He may then leave school with noqualifications, fail to find a job and resort to drugs. To fund his drug habit hemay turn to crime and, once convicted, find it even harder to get a job. From thisexample, it can be seen that adverse experiences do not only arise passively andindependently of the young person’s behaviour; rather, the behaviour predisposes
them to end up in increasingly risky and damaging environments. Consequently,
the number of adverse life events experienced is greatly increased. The path fromearly hyperactivity into later conduct disorder is also not inevitable. In the presenceof a warm supportive family atmosphere it is far less likely than if the parents arehighly critical and hostile.
Other influences can however steer the individual away from and antisocial
path. For example, the fascinating follow-up of delinquent boys to age 70 by Lauband Sampson showed that the following led to desistence: being separated from adeviant peer group; marrying to a non-deviant partner; moving away from a poor
neighbourhood; military service which imparted skills.

PRINCIPLES OF TREATMENT
1. Engage the family
Any family coming to a mental health service is likely to have some fears
about being judged as bad and possibly mad. Families of conduct problem
children are more likely to be disadvantaged and disorganised, to have hadarguments with official agencies such as schools and welfare officers and to besuspicious of officialdom. Dropout rates in treatment for conduct problem
families are high – often up to 60% (Kazdin, 1996). Practical measures,such as assisting with transportation, providing childcare and holding
sessions in the evening or at other times to suit the family are all likely tofacilitate retention. Forming a good alliance with the family is especially
important, and Prinz and Miller (1994) showed that adding engagement
strategies during the assessment, such as showing parents that the therapist
clearly understood their viewpoint, led to increased attendance at treatment
sessions. Once engaged, the quality of the therapist’s alliance with the family
affects treatment success, accounting for 15% of the variance in outcome in
the meta-analysis by Shirk and Carver (2003).
2. Select which treatment type to use and who should deliver it
If possible, interventions need to address each context specifically, rather
than assuming that successful treatment in one area will generalise toanother. Thus improvements in the home arising from a successful parent

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IACAPAP Textbook of Child and Adolescent Mental Healthtraining programme will not necessarily lead to less antisocial behaviourat school (Scott, 2008). If classroom behaviour is a problem and a school
visit shows that the teacher is not using effective methods, then advice tothe teacher and other school staff can be very effective. Where there arepervasive problems including fights with peers, then individual workon anger management and social skills should be added. Medication iscontroversial and generally best avoided; possible indications are discussed
below. Generally speaking, due to the strong evidence for its effectiveness,
the first line of treatment should be parent training.
Most countries have insufficient resources to treat all antisocial behaviour inchildhood, so a decision will need to be made as to whether other agencies
can be involved. Thus a number of voluntary sector bodies now provide
parent training and schools may also be able to set up suitable behaviouralprogrammes.
3. Develop strengths
Identifying the strengths of the young person and the family is crucial.
This helps engagement and increases the chances of effective treatment.
Encouragement of abilities helps the child spend more time behaving
constructively rather than destructively – e.g., more time spent playing
football is less time spent hanging round the streets looking for trouble.
Encouragement of prosocial activities – for example to complete a good
drawing or to play a musical instrument well – also increases achievements
and self-esteem and hope for the future.

Click on the picture to accessthe US Federal Government’ssite National Youth ViolencePrevention Resource Center
which has recent researchfindings and provides online
training for prevention.

4. Treat comorbid conditions
Child antisocial behaviour often affects others so strongly that comorbid
conditions can easily be missed. Yet, comorbidity is the rule rather than the
exception in clinical referrals. Common accompaniments are depression and
ADHD; a number will have PTSD, for example in the context of violence
inflicted on themselves by a father, or witnessing beatings received by theirmother from a partner.
5. Promote social and scholastic learning
Treatment involves more than the reduction of antisocial behaviour – thus
stopping tantrums and aggressive outbursts, while helpful, will not lead togood functioning if the child lacks the skills to make friends or to negotiate:
positive behaviours need to be taught too. Specific learning disabilities suchas reading retardation, which is particularly common in these children, needtreatment, as do more general difficulties such as planning homework.
6. Use guidelines
The American Academy of Child and Adolescent Psychiatry has publishedsensible practice parameters for the assessment and treatment of conductdisorder (AACAP 1997); the UK National Institute for Health and ClinicalExcellence (NICE) has published a “technology appraisal” of the clinicaland cost effectiveness of parent-training programmes (2006) and is due
to publish in 2013 a guideline on assessment and treatment of conductdisorders.

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IACAPAP Textbook of Child and Adolescent Mental Health

7. Treat the child in their natural environment
Most of the interventions described below are intended for outpatient orcommunity settings. Psychiatric hospitalization is very rarely necessary;
there no evidence that inpatient treatment leads to gains that are maintained
after the child is returned to their family.
Specific interventions
Family based
The best known in the context of delinquency is Functional Family Therapy(FFT), brought into being in 1969 by James Alexander and colleagues (Alexander
et al, 2000). It is designed to be practicable and relatively inexpensive; 8-12 onehour sessions are given in the family home to overcome attendance problems
common in this client group. For more intractable cases, 26-30 hours are offered,usually over three months. The target age range is 11-18. There are four phases
to treatment. The first two are the engagement and motivation phases. Here thetherapist works hard to enhance the perception that change is possible and tominimise perceptions that might signify insensitivity or inappropriateness (e.g.,poor programme image, difficult to access, insensitive referral). The aim is to keep
the family in treatment, and then to move on to find what precisely the family
wants. Techniques include reframing, whereby positive attributes are enhanced(e.g., a youth who offends a lot but doesn’t get caught is labeled as bright) and theemotional motivation is brought out (e.g., a mother who continually nags may belabelled as caring, upset and hurt).
Families are encouraged to see themselves as doing the best they can under
the circumstances. Problem-solving and behaviour change are not commenced until
motivation is enhanced, negativity decreased, and a positive alliance established.
Explicit attempts are made to reduce negative spirals in family interactions byinterrupting and diverting the flow of negative, blaming speeches. Reframes do
not belittle the impact of the negative behaviour, but each family member should
feel at the end of these two initial stages that:•

They are not inherently bad, it is the way they have done things that hasn’t
worked•Even though they have made mistakes, the therapist sided with them asmuch as with everybody else•

Even though they experience the problems differently, each family member
must contribute to the solution•

Even though they may have a lot to change, the therapist will work hard toprotect them and everyone else in the family•

They want to come back to the next session because it finally seems thatthings might get better.

Click on the picture to view

Preventing Violence andRelated Health-Risking
Behaviors in Adolescents,

a NIH Sate of the Science
Consensus Report.

The third phase of FFT targets behaviour change. There are two mainelements to this, communication training and parent training. The success of thisstage is dependent on the first two having been achieved and is not commenced
unless they have been (this differs from some programmes where a predetermined
number of sessions is allocated to each topic irrespective of the rate of family
progress). This stage is applied flexibly according to family needs. Thus if there are
two parents who continually argue and this is impinging on the adolescent, theConduct disorders

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IACAPAP Textbook of Child and Adolescent Mental Health“marital subsystem” will be addressed, using standard techniques, These include:
1. Using the first person voice rather than the second (instead of “you are alazy slob”, “I find it upsets me when you leave your socks on the floor”)
2. Being direct (instead of complaining to partner “he never…”, say it directly
to the youth)
3. Brevity instead of long speeches
4. Behavioural specificity about what is desired
5. Offering alternatives to the young person, and6. Active listening.
Parent training techniques are similar to those found in standard approaches
and include praise, rewards (called contracting in FFT – e.g., if you come homeby 6pm each night, I will take you to the cinema on Saturday), limit setting,consequences and response-cost (e.g., losing TV time for swearing).
The fourth and final phase of FFT is generalisation. Here the goal is to get
the improvements made in a few specific situations to generalise to other similarfamily situations, to help the youth and family negotiate positively with community
agencies such as school, and help them get the resources they need. Sometimes thislatter goal may require the therapist to be a case manager for the family. Therefore,
to do this requires that the therapist knows the community agencies and how thesystem works.
EffectivenessThe effectiveness of FFT is well established, there have been over 10
replication studies (Alexander et al, 2000), of which over half have been independentof the developers, and four are underway in Sweden. The trials published to date
all have been positive, with typical recidivism rates being 20% to 30% lower thanin controls.
Multiple component interventions
Multisystemic Therapy
The example of Multisystemic Therapy (MST) will be taken as it is one of
the best treatments of this kind. MST was developed by Henggeler and colleagues
in the US (Huey et al, 2000). There are nine treatment principles:
1. An assessment should be made to determine the fit between the problems
and the wider environment: difficulties are understood as a reaction to a
specific context, not seen as necessarily intrinsic deficits
2. Therapeutic contacts emphasize the positive and use systemic strengths aslevers for change. Already the assessment will have identified strengths (suchas being good at sports, getting on well with grandmother, the presence of
prosocial peers in grandmother’s neighbourhood). The implementation ofthis principle means that each contact should acknowledge and work onthese.
3. Interventions are designed to promote responsible behaviour and decreaseirresponsible behaviour.
4. Interventions are focused in the present, are action oriented, and havespecific, well-defined goals. The approach is what can be done in the

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IACAPAP Textbook of Child and Adolescent Mental Healthhere and now, in contrast to some therapies that emphasise the need tounderstand the family and the youth’s past.
5. Interventions target sequences of behaviour in multiple systems thatmaintain problems.
6. Interventions are developmentally appropriate. They should fit the life stage
and personal level of the family members.
7. Interventions require daily or weekly effort by family members. This enables
frequent practice of new skills and frequent positive feedback for efforts
made. Non-adherence to treatment agreements rapidly becomes apparent.
8. The effectiveness of the intervention is evaluated continuously frommultiple perspectives with the intervention team assuming responsibility forovercoming barriers to successful outcomes.
9. Interventions are designed to promote treatment generalization byempowering parents to address the youth’s needs across multiple contexts.
The way the therapy is delivered is closely controlled. Due to the weekly
monitoring of progress; if there are barriers to improvement, these should be
rapidly addressed and the hypotheses of what is going on in the family and systems
around the youth should be revised in the light of progress. Clinicians only takeon 4-6 cases since the work is intensive. There is close attention to quality control
by weekly supervision along prescribed lines and parents and youths themselves fillin weekly questionnaires on whether they have been receiving therapy as planned.
Therapy is given for three months and then stopped.
Effectiveness
The first raft of outcome studies by the programme developers was positive.
Thus the meta-analysis of papers up to and including 2002 by authors that include
one of the programme developers, Charles Borduin, found that in 7 outcome
studies comparing MST to treatment as usual or an alternative with 708 youths
by 35 therapists, the mean overall effective size across several domains was 0.55
(Curtis et al, 2004). Outcome domains ranged from offending (arrests, days inprison, self-reported criminality, self reported drug-use) where the mean effect size(ES) was 0.50, peer relations (ES: 0.11), family relations (self-reported ES: 0.57,
observed ES: 0.76), and individual youth and parent psychopathology symptoms(ES: 0.28). However, the three studies using the developers own graduate students
as therapists achieved noticeably larger effect sizes (mean 0.81) than when thedevelopers were supervising local community therapists, where the effect size mean
was down to 0.26.
Long-term follow-up 14 years later (when participants’ mean age was
29 years) by the developers of one of the first trials (with 176 cases allocatedto MST or usual individual therapy), gave recidivism rates of 50% vs 81%
respectively. However, in the process of evaluation, the next test of any therapy is
its effectiveness when carried out by teams who have no financial or employmentties with the developers (although they may pay the developers for materials andsupervision) and with an independent evaluation team (Littell, 2005). The only
independent evaluation was also the only one to use proper intention to treat
analyses (rather than exclude treatment refusers etc.) in a large sample (n=409)
in Ontario, Canada. It found that MST resulted in no improvement compared

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IACAPAP Textbook of Child and Adolescent Mental Healthwith treatment as usual on any outcome, either immediately or by the three year
follow up (Lescheid & Cunningham, 2002). A smaller (n=75) independent study
in Norway (Ogden & Hagen, 2006) was more positive, founding ESs of 0.26
for self-reported delinquency, 0.50 for parent-rated, and 0.68 for teacher-rated,though here there was 40% missing data.
Interventions that do not work
Harsh, military style shock incarceration, so-called “boot camps”, are still
popular for young offenders in the US and were promoted by the Office of Juvenile
Justice and Delinquency Prevention in 1992 when 3 pilot programmes were set
up. However, several reviews have concluded they are ineffective (Tyler et al, 2001;
Stinchcomb, 2005; Benda, 2005; Cullen et al, 2005). A randomized control trial
by the California Youth Authority that included long-term arrest data found nodifference between boot camp and standard custody and parole (Bottcher & Ezell,2005). In contrast, a meta-analysis of 28 studies of wilderness programmes found
an overall effect size of 0.18, with recidivism rates of 29% vs 37% for controls(Wilson & Lipsey 2000). Programmes with intense physical activity and a distinct
therapeutic component were the most effective. Another approach is to seek tofrighten young delinquents with visits to prisons in an attempt to deter them,for example in the “Scared Straight” programme. However, a meta-analysis ofnine controlled trials found that the intervention is on average more harmful thandoing nothing; it led to worse outcomes in the participants (Petrosino et al, 2003).
Medication
At present, there are no pharmacological interventions approved specificallyfor conduct disorder. Nonetheless, in the US, medications are used relatively
frequently and increasingly in this population (Steiner et al, 2003; Turgay,2004). Primary care physicians are often placed in the position of managing such
medications. Concerns have been raised because primary care clinicians often
lack training in developmental psychopathology and adequate time for thoroughassessment and monitoring (Vitiello, 2001). In the UK medication would not

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At present, there areno pharmacologicalinterventions approved
specifically for conductdisorder.

23

IACAPAP Textbook of Child and Adolescent Mental Healthgenerally be supported as good practice because, as discussed below, well-replicatedtrials of effectiveness are limited, particularly for children without ADHD.
The best-studied pharmacological interventions for youth with conduct
problems are psychostimulants (methylphenidate and dexamfetamine), as used withchildren with co-morbid ADHD and conduct disorder. In these circumstances,
there is evidence that reduction in hyperactivity/impulsivity will also result in
reduced conduct problems (Connor et al, 2002; Gerardin et al, 2002). There isinsufficient reliable evidence to decide whether stimulants reduce aggression in theabsence of ADHD; one study by Klein et al (1997) found that improvements in
conduct disorder symptoms were independent of ADHD symptom reduction, but
this needs replication.
Other pharmacological approaches for antisocial behaviour targeted reactive
aggression and over-arousal, primarily in highly aggressive and psychiatrically
hospitalised youth. Medications used in these conditions include those purported
to target affect dysregulation (e.g., buspirone, clonidine) and mood stabilizers(e.g., lithium, carbamazepine). While Campbell et al found that lithium reduced
aggression and hostility in psychiatrically hospitalized youth (Campbell et al, 1995;
Malone et al, 2000), others failed to show effectiveness in outpatient samples (e.g.,
Klein, 1991) and in studies of shorter treatment intervals (i.e., 2-weeks or less)(Rifkin et al, 1997). Carbamazepine failed to outperform placebo in a doubleblind placebo controlled study (Cueva et al, 1996). In children with aggression
and hyperactivity, Hazell and Stuart (2003) in a placebo controlled, randomized
trial of stimulants plus placebo versus stimulants plus clonidine found the latter
was more effective. However, it should be noted that polypharmacy carries the riskof increased side effects (Impicciatore et al, 2001).
In the last few years, the use of antipsychotics such as risperidone, and otherdrugs such as clonidine in outpatient settings has been increasing. However, there
is only modest evidence for their effectiveness in conduct disorder in normal IQ
children without ADHD. The review by Pappadopoulos et al (2006) found thatESs were larger where ADHD or intellectual disability were present. Findling etal (2000), in a small (n=10 per group), double blind, placebo-controlled study,
found significant short-term reduction in aggression. The Risperidone Disruptive
Behaviour Study Group used a placebo-controlled, double blind design to
examine the effects of risperidone in 110 children with subaverage IQ and conduct
problems. Results suggest that risperidone resulted in significant improvements inbehaviour versus placebo (Aman et al, 2002; Snyder et al, 2002) but it remains
unclear whether the same findings would apply to children with normal IQ. Newer
antipsychotics, while not especially sedating, have substantial side-effects, forexample risperidone typically leads to considerable weight gain and the prevalenceof long-term movement disorders in the long-term is unknown (Reyes et al, 2006).
When antipsychotics might be contemplated? Clinical experience suggests they
can lead to dramatic reductions in aggression in some cases, especially where
there is poor emotional regulation characterized by prolonged rages. Prescribing
antipsychotics for relatively short periods (for example, up to 4 months) in low
doses (e.g., no more than 1 mg to 1.5 mg of risperidone per day) can help families
cope. During this time it is crucial to introduce more effective psychologicalmanagement. However, antipsychotics are not recommended in anything otherthan unusual circumstances.

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