Conduct Disorder

Question 1

what is conduct disorder?

Answer 1

A repetitive and persistent pattern of behaviour in which the basic rights of others or major age appropriate societal norms or rules are violated.- Pisano et al., 2017

Question 2

how frequent is CD in terms of other clinical conditions

Answer 2

CD is among the most frequent clinical conditions in child and adolescent mental health – Gritti et al., 2014

Question 3

DSM-5 diagnosis of CD

Answer 3

• Aggression to people and animals e.g. often initiates physical fights
• Destruction of property e.g. has deliberately destroyed others’ property
• Deceitfulness or theft- e.g. has broken into someone else’s house/building/car
• Serious violation of rules- e.g. often stays out at night despite parental prohibitions, beginning before age 13.

For a diagnosis there needs to be at least 3 of the 15 criteria in the past 12 months from any of the four categories, with at least one criterion present in the past 6 months.

Question 4

what is the new DSM-V specifier for CD?

Answer 4

with limited prosocial emotions” (LPE); 
•	Lack of remorse/ guilt
•	Callous-lack of empathy 
•	Unconcerned about performance 
•	Shallow or deficient affect

Question 5

what is the new DSM specifier supposedly there to do?

Answer 5

to classify a specific subgroup of antisocial youth with distinguishing antisocial behaviors and psychopathic traits. The provision of the CU specifier for CD youth is claimed to improve the diagnostic power, treatment options, and increase the understanding life-course outcomes (Frick and White 2008)

Question 6

what are onset types of CD

Answer 6

Onset:
• Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years.
• Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years.
• Considered CD if the individual is age 18 years or older and criteria for antisocial personality disorder is not met.

Question 7

who proposed two distinct types of CD? and what were these?

Answer 7

Moffitt 2006, 2007

• Life course-persistent (10-15x more common in boys than in girls
• Adolescence-limited

Question 8

discuss psychopathy and CD

Answer 8

Psychopathic traits, previously considered as a meaningful (negative) specifier for severe antisocial and aggressive behaviours in adult psychopathology, have been re-discovered as a relevant factor in subtyping CD in youth- Frick et al., 2000

Frick 2000- confirmed that the multidimensional structure of adult psychopathy is detectable also in the adolescent populations. Furthermore, studies on children/adolescents strongly suggested the association between psychopathic personality traits and conduct problems (CP), namely aggression and law violation (Stams et al., 2011)

Question 9

what future life events are those with CD liable to

Answer 9

psychopathy (Cu traits?)

Antisocial personality disorder

crime

substance use

mental health disorders

lower educational achievment and employment outcomes

being male??

Question 10

talk about antisocial personality disorder and CD

Answer 10

25-40% of youths with conduct disorder will develop antisocial personality disorder (Pickles et al., 1992).

Nonetheless, many of the individuals who do not meet full criteria for antisocial personality disorder still exhibit a pattern of social and personal impairments or antisocial behaviors (Rutter 1989)

Question 11

which study uncovered a large number of future life traits for those with CD and what were these?

Answer 11

Fergusson et al., 2005
25-year longitudinal study to examine the linkages between conduct problems in middle childhood (7–9 years) and later adjustment in young and adulthood (21–25 years).
Crime:
• Strong statistically significant associations between extent of early conduct problems and later crime.
• Particularly marked for measurements of violent offending, arrest and imprisonment
• Most disturbed 5% of the cohort had rates of offending that were over 10x higher than rates for those in least disturbed 50%
Substance use behaviours
• Significant associations between CD and nicotine dependence and illicit drug dependence.
Mental health disorders= significant
Increased risk of adverse sexual or partner relationships:
• + likely to have multiple sexual partners
• + likely to have teenage pregnancy and parenthood
• + involvement in domestic violence
Educational achievement and employment outcomes
• Significant link between CD and lower levels of educational achievement and higher rates of unemployment and welfare dependence.  however these have both been linked to earlier lower IQ in childhood.

On the basis of these findings it may be suggested that early conduct problems are likely to act as one of the most important factors in determining long-term psychosocial outcomes

Question 12

talk about gender differences in CD

Answer 12

Lahey et al., 2006; Moffit et al., 2001
• Considerably more common in males
• Males outnumber females in the onset of CD by 3:1

Question 13

what are the risk factors for CD

Answer 13

Neurobiological:

1) Brain difference
2) Impaired punishment processing
3) Neurotransmitters

GENETIC

GENETIC X ENVIRONMENT

LOW IQ

SOCIAL & ENVIRONMENT:

1) Parenting
2) SES

Question 14

talk about grey matter volume in CD

Answer 14

Sterzer et al., 2007
Grey matter volume in bilateral anterior insular cortex and the left amygdala was significantly reduced in CD patients compared to healthy control subjects. Was a negative correlation also of anterior insular grey matter volume with empathy levels in CD. In early adolescents with CD

Question 15

what two brain areas have been implicated in CD

Answer 15

grey matter volume in bilateral anterior insular cortex and left amygdala= significantly reduced

Question 16

amygdala size in CD study

Answer 16

Sterzer et al., 2005 found reduced amygdala volume also
The finding of reduced amygdala volume is in line with evidence from functional imaging studies showing dysfunction of this structure in adult psychopaths (Kiehl et al., 2001).
Amygdala plays a central role in regulating social interactions as it mediates the processing of emotional stimuli. Amygdala function is thus a key determinant of behavioural responses to emotional information and a reduction of amygdala volume is in keeping with current models regarding the mechanisms that underlie aggressive behaviour (Blair 2005; Dolan, 2002)

Question 17

discuss impaired punishment processing in CD

Answer 17

• Low fear of punishment would reduce effectiveness of conditioning
• Reduced skin conductance in anticipation of punishment shows this lack of fear. It has been proposed that individuals fail to learn successful associations between antisocial acts and punishments.
• Gao et al., 2010- Prospective study fear conditioning using electrodermal responsivity was assessed in children at ages 3-8. Was shown that poor fear conditioning from ages 3-8 is associated with aggression at age 8
• Lorber 2004 meta analysis- lower basal skin conductance levels were found in preschool children with aggressive behaviour compared to nonaggressive pre-schoolers (Posthumus et al., 2009)

Question 18

meta-analysis of heritability of antisocial behaviour

Answer 18

Meta-analysis of twin and adoption studies suggest 40 – 50% of antisocial behavior is heritable (Rhee & Wheldman, 2002)
• Genetics a stronger influence when behaviors begin in childhood rather than adolescence

Question 19

what hints to genetic factors of CD

Answer 19

clear that antisocial parents tend to have antisocial children. In Pittsburgh youth study parents with behaviour problems and substance use problems tended to have boys with CD- Loeber 1998

Question 20

talk about genetic x environment in CD

Answer 20

Caspi et al., 2002- The analyses revealed consistent evidence of Genetic × Environmental interactions, with those having the low-activity Monoamine oxidase (MAOA) variant and who were exposed to abuse in childhood being significantly more likely to report later offending, conduct problems and hostility.

Question 21

talk about low IQ and CD

Answer 21

epidemiologic study of twins aged 13 years, low IQ of the child predicted conduct problems independently of social class and of the IQ of parents- Goodman 1995

Study by West and Farringdon 1973 twice as many of the boys scoring 90 or less on a nonverbal IQ test at age 8 to 10 years were convicted as juveniles, compared with those scoring above

• Other studies have shown that, even when low IQ is measured at age 3 to 4 years, it predicts delinquency in young adulthood. – Lipsitt et al., 1990

Question 22

discuss general social and environmental influences on

Answer 22

• Loeber 1998- boys with CD tended to have parents who had unhappy relationships.
• Children who had witnessed violence between their parents were more likely to commit both violent and property offences according to their self-reports- Fergusson and Horwood 1998
• Parental separation and single parenthood predict CD in children. Seperations from parents in first 5 years of life predicted CD at age 15 years. Fergusson et al.,1994
• CD strongly predicted by having a never married lone mother- Cohen et al., 1989
• Peer influence (Moffitt, 1993, 2003)- Affiliation with deviant peers- Acceptance or rejection by peers

Question 23

talk about parenting and CD

Answer 23

Scott (1998) found 5 aspects of parenting that have been found repeatedly to have long-term associations with conduct disorder these are:
1. • poor supervision;
2. • erratic harsh discipline;
3. • parental disharmony;
4. • rejection of the child;
5. • low parental involvement in the child’s activities.
Such parenting appears to be a major cause of conduct disorders in children.

Question 24

talk about SES and CD

Answer 24

• Children with CD tended to come from low-income families, with unemployed parents living in subsidized housing and dependant on welfare benefits- Farrington & Welsh, 2007.
• While in another study low SES, low family income and low parental education predicted children with CD- Cohen et al., 1989
• Researchers have suggested that the link between low SES families and antisocial behaviour is mediated by family socialization practices. In other words low SES predicts CD because SES families use poor childrearing practices- and good parenting has been shown to alleviate CD.

Question 25

what conclusions can be drawn regarding risk factors in CD

Answer 25

While the precise causal chains that link these factors with antisocial behaviour, and the ways in which these factors have independent, interactive, or sequential effects, are not well understood, it is clear that numerous replicable risk factors have been identified. Early prevention programs targeting individual, family, and social risk factors have shown impressive results in reducing later CD and delinquency ( Farrington DP, Welsh 2007)

Question 26

list the different treatment methods to CD

Answer 26

Problem -solving skills training

Parental Management Training

Combination of the two

MULTISYSTEMIC THERAPY

pharmacotherapy — antipsychotic medication

Question 27

what suggested the problem-solving skill training may work as a treatment method for CD

Answer 27

• Cognitive processes are frequently accorded a major role in conduct problems (Shirk, 1988)
• As a case in point, aggression is not merely triggered by environmental events but, rather, through the way in which these events are perceived and processed.

Question 28

what is the basis of problem-solving skills training?

Answer 28

• Consists of developing interpersonal cognitive problem-solving skills emphasis placed on how children approach situations and second children are taught to engage in a step-by-step approach to solve interpersonal problems.

Question 29

which studies have shown efficacy in patient samples

Answer 29

• several studies have shown therapeutic change in patient samples (e.g.; Kazdin et al., 1992; Kendall et al.,, 1990; Yu,1986)

Question 30

who is it suggested that treatment is better with for problem-solving skills training?

Answer 30

• Evidence has suggested that treatment is more effective with older rather than younger children (Durlak et al., 1991), consistent with a view that individuals with higher levels of cognitive development profit more from a cognitively based treatment.

Question 31

what are issues with PSST

Answer 31

reliable changes have been achieved with treatment but the magnitude of change has left a great deal to be desired. Many youth improve but remain outside of the range of normative functioning relative to same-age and -sex peers (e.g., Kazdin et al., 1989, 1992)
-few studies have elaborated the factors that contribute to treatment outcome

Question 32

what is Parental Managment training (PMT)

Answer 32

• Procedures in which parents are trained to alter their child’s behaviour in the home.
• Parents meet with therapist/ trainer who teaches them to use specific procedures to alter interactions with their child to promote prosocial behaviour and to decrease deviant behaviour.

Question 33

what is PMT based on the view of?

Answer 33

based on the general view that conduct problem behaviour is inadvertently sustained in the home by maladaptive parent-child interactions.

Question 34

who has shown efficacy of PMT

Answer 34

• Kazdin 1987 and Kazdin et al., 1992 shown effectiveness of PMT in children with conduct problems
.
• Forehand and long 1988; showed that the continued benefits of treatment have been evident up to 10 years after treatment

Question 35

what are issues with PMT

Answer 35

• Requires active participation on the part of the parent makes treatmenr inapplicable to some cases where parent dysfunction and unwillingness cannot be surmounted.
• May be more difficult to apply with adolescent youth as contingencies that parents can control are more limited and time youth spend in house is less.

Question 36

who suggested that a combo of PSST and PMT were best and why

Answer 36

Kazdin, Siegal and Bass, 1992
In the present example, 97 children (ages 7-13) participated (Kazdin et al., 1992). The majority of youth met DSM-III-R criteria for CD or oppositional disorder. Most of the children (71%) met criteria for more than one disorder. Youth were assigned randomly to one of three conditions: PSST, PMT, or the combination of PSST + PMT. Individual sessions were provided for children (PSST) and/or parents (PMT)
The results indicated that each of the treatments produced change. Among the three treatments, PSST + PMT combined led to more marked changes in child and parent functioning and placed a greater proportion of youth within the range of nonclinic (normative) levels of functioning at home and at school. These effects were evident at posttreatment as well as at 1-year follow-up assessment.

Question 37

what is reasoning behind multisystemic therapy?

Answer 37

Whilst research indicates that adolescent offending is multidetermined with risk factors across a range of systems; very few interventions have adopted a structured multimodal approach.

Question 38

what is MST

Answer 38

One such programme is MST which is an ecologically driven and intensively delivered family and community based intervention

Question 39

what is a key feature of MST

Answer 39

the consideration of all of the relevant risk and protective factors present across the ‘systems’ around the adolescent which impede or support their involvement in antisocial behaviour

Question 40

how is MST delivered?

Answer 40

by a small team of therapists primarily in the family home; but also alongside schools, other community agencies and extended family as needed.

Question 41

who inveted MST?

Answer 41

Henggler & Borduin 1990

Question 42

generally what are findings of MST?

Answer 42

mixed

Question 43

studies that support MST

Answer 43

Prins et al., 2012–Decrease in CD symptoms improvement in parental sense of competence adolescents hostility.
Study of violent and chronic juvenile offenders; Borduin et al., 1995), MST demonstrated extensive improvements in family relations and, most significantly, a 63% decrease in recidivism at a 4-year follow-up
Sawyer and Borduin (2011) showed that MST produced a 36% reduction in felony rearrests and a 33% reduction in days in adult confinement 22 years post treatment.
*in these studies Borduin provided all training and clinical supervision

Question 44

evidence against MST

Answer 44

review by Littell et al., 2005 concluded that MST is not consistently more effective than alternatives for adolescents with serious conduct problems.
Markham 2016 points out that the majority of randomised control trials (RCTs) had been undertaken by the MST developers 5 themselves under optimal conditions

Question 45

in which patients may drugs be useful for? and which drugs

Answer 45

atypical antipsychotic treatment may be useful in patients with these conditions who present with problematic aggression

Question 46

what is the atypical antipsychotic proposed for treating CD and what does this do and what else is it used to treat?

Answer 46

Quetiapine–> antipsychotic used for the treatment of schizophrenia, bipolar disorder, and major depressive disorder. Has a sedating effect.

Question 47

support for atypical antipsychotic use

Answer 47

Connor et al., 2007- 7-week, randomized, double-blind, placebo-controlled pilot study with two parallel arms. Nine youths were randomly assigned to receive quetiapine, and 10 youths were randomly assigned to receive placebo. Patients were assessed weekly throughout the trial.
Quetiapine was superior to placebo on all clinician-assessed measures and on the parent-assessed quality of life rating scale. provides data that quetiapine may have efficacy in the treatment of adolescents with conduct disorder.

Question 48

study on DSM-III revised and girls

Answer 48

Zoccolillo et al., 1996 aimed to determine whether DSM-III criteria for CD identify girls in the general population with early-onset persistent and persuasive anti-social behaviour. This study supports negative critiques in this area. Recruited over 4,000 children attending kindergarten in a longitudional study. Parents and teachers completed a measure of social behaviours.
At age 10 years, the girls who been rated as antisocial in kindergarten, along with a random sample of those not rated as antisocial, were assessed for DSM-III and diagnoses of conduct and oppositional defiant disorder using a structured psychiatric interview (Diagnostic Interview Schedule for Children) administered to the parent, teacher, and/or child (n = 381).
Of the girls with early-onset persistent and persuasive antisocial behaviour, only 3% met DSM-III revised criteria for CD. Authors concluded that DSM-III-R criteria for conduct disorder do not identify most preadolescent girls with early-onset, pervasive, and persistent antisocial behavior.
A lot of girls may be missing out on a diagnosis of CD

Question 49

what is an issue with predicting life course in CD dianosis?

Answer 49

Many of the critiques of life course persistent trajectories focus on methodological issues. CD for example supposedly captures the prominent symptoms of youth at risk of becoming delinquent later in life. However, the criteria for diagnosing conduct disorder are criticized for gender biases that increase the likelihood of a male diagnosis (Lober et al., 1999) because the current criteria do not include young womens modes of expressing aggression of early manifestations of antisocial behaviour. Problematic behaviours often remain stable over time and lead to significant involvement in mental health, juvenile justice and other social service systems during adolescence and/ or adulthood (Benson, 2002; Lober et al., 2000).

Question 50

what explains findings of male and female differences in DSM diagnosis?

Answer 50

Crick and Grotpeter 1995:
Prior studies of childhood aggression have demonstrated that, as a group, boys are more aggressive than girls. We hypothesized that this finding reflects a lack of research on forms of aggression that are relevant to young females rather than an actual gender difference in levels of overall aggressiveness. In the present study, a form of aggression hypothesized to be typical of girls, relational aggression, was assessed. Overt aggression (i.e., physical and verbal aggression as assessed in past research) and social- psychological adjustment were also assessed.
Relational aggression or is a type of aggression in which harm is caused by damaging someone’s relationships or social status.
Results provide evidence for the validity and distinctiveness of relational aggression. Further, they indicated that, as predicted, girls were significantly more relationally aggressive than were boys.
Results also indicated that relationally aggressive children may be at risk for serious adjustment difficulties (e.g., they were significantly more rejected and reported significantly higher levels of loneliness, depression, and isolation relative to their nonrelationally aggressive peers).–> rejection= major risk factor in CD

Bjorkqvist et al., 1992
Previously, the main difference between the genders has been thought to be that boys use physical aggressive strategies, while girls prefer verbal ones. Our studies suggest that the differentiation between direct and indirect strategies of aggression presents a more exact picture. Indirect aggressive strategies were not yet fully developed among the 8‐year‐old girls, but they were already prominent among the 11‐year‐old girls.

Question 51

discuss peer rejection

Answer 51

• Coie et al., 2002
• These results support the hypothesis that the experience of peer rejection in the early school years adds to the risk for early starting conduct problems.
• effects of rejection on the child’s increased hostility and suspicion toward peers Because these rejected, aggressive children are more prone to anger themselves, as well as having fewer social skills for mediating peer distress, they may be more likely to get into escalating clashes with others, thus setting a pattern of greater interpersonal violence with peers
•

Question 52

what is CD comorbid with?

Answer 52

Oppositional defiant disorder and ADHD