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9
Conduct Problems
Eric J. Mash
A. Wolfe
©David
Cengage Learning
2016
© Cengage Learning 2016
Description of Conduct Problems
• Age-inappropriate actions and attitudes
that violate family expectations, societal
norms, and personal or property rights of
others
• These disruptive and rule-violating
behaviors range from:
– Annoying minor behaviors (e.g., temper
tantrums) to serious antisocial behaviors (e.g.,
vandalism, theft, and assault)
© Cengage Learning 2016
Description of Conduct Problems (cont’d.)
• We must consider many types, pathways,
causes, and outcomes of conduct
problems
• Are associated with unfortunate family and
neighborhood circumstances
– Circumstances do not excuse the behavior,
but help us understand and prevent it
© Cengage Learning 2016
Context
• Antisocial behaviors appear and decline
during normal development
– Behaviors vary in severity, from minor
disobedience to fighting
– Some may decrease with age; others
increase with age and opportunity
– Are more common in boys in childhood
– Children who are the most physically
aggressive in early childhood maintain relative
standing over time
© Cengage Learning 2016
Frequencies for Common Antisocial
Behavior
© Cengage Learning 2016
Social and Economic Costs
• Conduct problems are the most costly
mental health problem in North America
• Early, persistent, and extreme antisocial
behavior occurs in about 5% of children
– These children account 50% of all crime in the
U.S. and approximately 30-50% of clinic
referrals
– Annual public costs (healthcare, juvenile
justice, and educational systems) are $10,000
per child
© Cengage Learning 2016
Legal Perspectives
• Juvenile delinquency
– Legal definitions exclude antisocial behaviors
of very young children
– Including property crimes (e.g. vandalism,
theft), violent crimes (robbery, aggravated
assault, homicide)
– Minimum age of responsibility is 12 (in most states)
– Only a subgroup of children meeting legal
definition of delinquency also meet definition
of a mental disorder (needs to show
persistent pattern)
© Cengage Learning 2016
Psychological Perspectives
• Conduct problems fall on a continuous dimension
– Externalizing dimension: Impulsive and overactive
• “Rule-breaking behavior”: running away, setting fires,
stealing, dugs, vandalism, skipping school
• “Aggressive behavior” : Fighting , destructiveness,
disobedience, defiance, threatening
– Overt (visible) –covert (hidden) dimension
– (Most children with CD display both)
– Destructive-nondestructive dimension
– Crossing the overt-covert with the destructive-nondestructive
• Yields four categories of conduct problems
© Cengage Learning 2016
Four Categories of Conduct Problems
© Cengage Learning 2016
Examples of the two dimensions
• Covert (hidden)- Destructive:
Property violations: vandalism, stealing, fires,
cruelty to animals; also lying
• Covert- Non-Destructive:
Runway, truancy, substance use, breaks rules
• Overt (Open)-Destructive:
Aggression, fight, bullying, Spiteful
• Overt- Non-Destructive (oppositional)
Argues, temper, defies, stubborn, annoys, touchy
© Cengage Learning 2016
Psychiatric Perspectives
• Conduct problems are viewed as distinct
mental disorders based on DSM
symptoms
– Disruptive behaviors are described as
persistent patterns of antisocial behavior
– Represented by the categories of Conduct Disorder (CD) and
Oppositional Defiant Disorders (ODD)
• The diagnosis of antisocial personality
disorder (APD) is relevant to
understanding childhood conduct and their
adult outcomes
© Cengage Learning 2016
Public Health Perspectives
• Blends the legal, psychological, and
psychiatric perspectives with public health
concepts of prevention and intervention
– Goal
• To reduce injuries, deaths, personal suffering, and
economic costs associated with youth violence
• Cut across disciplines to:
– Understand conduct problems in youths
– Determine how these problems can be
treated and prevented
© Cengage Learning 2016
DSM-5 Defining Features
• Two DSM-5 disruptive behavior disorders
– Oppositional defiant disorder (ODD)
– Conduct disorder (CD)
– Both have been found to predict future
psychopathology and enduring impairment in
life functioning
© Cengage Learning 2016
Oppositional Defiant Disorder
• Age-inappropriate recurrent pattern of
stubborn, hostile, disobedient, and defiant
behaviors
• Usually appears by age 8
• Severe ODD behaviors can have negative
effects on parent-child interactions
• Symptoms can be grouped into
• 1)Negative affect ( angry, irritable mood)
• 2) Defiance (defiant/strong-head behavior
© Cengage Learning 2016
Diagnostic criteria for Oppositional Defiant
Disorder
© Cengage Learning 2016
Diagnostic criteria for Oppositional Defiant
Disorder (cont’d.)
© Cengage Learning 2016
Conduct Disorder
• Repetitive, persistent pattern of severe
aggressive and antisocial acts
– May have co-occurring problems, e.g.,
ADHD, academic deficiencies, and poor peer
relations
– Family child-rearing practices may contribute
to problems
– Parents feel the children are out of control
and feel helpless to do anything about it
© Cengage Learning 2016
Diagnostic Criteria for Conduct Disorder
© Cengage Learning 2016
Diagnostic Criteria for Conduct Disorder
(cont’d.)
© Cengage Learning 2016
Diagnostic Criteria for Conduct Disorder
(cont’d.)
© Cengage Learning 2016
Conduct Disorder Age of Onset
• Children with childhood-onset CD display
at least one symptom before age 10
– More likely to be boys
– Show more aggressive symptoms
– Account for disproportionate amount of illegal
activity
– Persist in antisocial behavior over time
© Cengage Learning 2016
Conduct Disorder Age of Onset (cont’d.)
• Children with adolescent-onset CD
– As likely to be girls as boys
– Do not show the severity or psychopathology
characterizing the early-onset group
– Are less likely to commit violent offenses or
persist in their antisocial behavior over time
© Cengage Learning 2016
Are CD and ODD Separate?
• Nearly half of all children with CD have no
prior ODD diagnosis
• Most children who display ODD do not
progress to more severe CD
• For most children, ODD:
– Is an extreme developmental variation
– Is a strong risk factor for later ODD
– Does not signal an escalation to more serious
conduct problems
© Cengage Learning 2016
Antisocial Personality Disorder (ADP) and
Psychopathic Features
• Pervasive pattern of disregard for and
violation of the rights of others;
involvement in multiple illegal behaviors
– As many as 40% of children with CD later
develop APD
– Adolescents with APD may display
psychopathic features
– Signs of lack of conscience occur as young as
3-5 years
© Cengage Learning 2016
Antisocial Personality Disorder (ADP) and
Psychopathic Features (cont’d.)
• A subgroup of children with CD are at risk
for extreme antisocial and aggressive acts
and for poor long-term outcomes
– Display callous and unemotional (CU)
interpersonal style
• Lack guilt and empathy; do not show emotions;
display narcissism and impulsivity; and lack
behavioral inhibition
– Different developmental processes may
underlie behavioral and emotional problems
© Cengage Learning 2016
Associated Characteristics
• Many factors are associated with conduct
problems in youths
– Cognitive and verbal deficits
– School and learning problems
– Self-esteem deficits
– Peer problems
– Family problems
– Health-related problems
© Cengage Learning 2016
Cognitive and Verbal Deficits
• Most children with conduct problems have
normal intelligence
• Verbal deficits are present in early
development: may interfere with self-control,
emotional regulation, receptive listening,
expressive speech
• Deficits in executive functioning
– Co-occurring ADHD may be a factor
– Types of executive function exhibited may differ - cool : attention,
working memory, planning and inhibition, (such as in ADHD) versus
hot executive functions: involve incentive and motivation (more often in
CD).
© Cengage Learning 2016
Deficits in Executive Functions
• Rarely consider the consequences of their
behavior or the impact on others
• Fail to inhibit their impulsivity
• Fail to consider future rewards
• Fail to adapt their action to future
circumstances
• May be related to the comorbidity with
ADHD
© Cengage Learning 2016
School and Learning Problems
• Underachievement, grade retention,
special education placement, dropout,
suspension, and expulsion
• Relationship between conduct problems
and underachievement is firmly
established by adolescence
– May lead to anxiety or depression in young
adulthood
© Cengage Learning 2016
Family Problems
• General family disturbances
• Specific disturbances in parenting
practices and family functioning
• High levels of conflict are common in the
family, especially between siblings
• Lack of family cohesion and emotional
support
• Deficient parenting practices
• Parental social-cognitive deficits
© Cengage Learning 2016
Peer Problems
• Young children with conduct problems
display poor social skills and verbal and
physical aggression toward peers
• Often rejected by peers, although some
are popular
– Children rejected in primary grades are five
times more likely to display conduct problems
as teens
– Some become bullies
© Cengage Learning 2016
Peer Problems (cont’d.)
• Often form friendships with other antisocial
peers
– Predictive of conduct problems during
adolescence
• Underestimate own aggression and its
negative impact, and overestimate others’
aggression toward them
© Cengage Learning 2016
Peer Problems (cont’d.)
• Reactive-aggressive children display
hostile attributional bias
• Proactive-aggressive view their aggressive
actions as positive
© Cengage Learning 2016
Self-Esteem Deficits
• Low self-esteem is not the primary cause
of conduct problems
– Instead, problems are related to inflated,
unstable, and/or tentative view of self
• Youths with conduct problems may
experience high self-esteem
– Over time may permit them to rationalize their
antisocial conduct
© Cengage Learning 2016
Health-Related Problems
• High risk for personal injury, illness, drug
overdose, sexually transmitted diseases,
substance abuse, and physical problems
as adults
• Rates of premature death (before age 30)
– Are 3 to 4 times higher in boys with conduct
problems
© Cengage Learning 2016
Health-Related Problems (cont’d.)
• Early onset and persistence of sexual
activity and sexual risk-taking by age 21
• Substance use disorders and adolescent
antisocial behavior are strongly associated
• Childhood conduct problems are a risk
factor for adolescent and adult substance
abuse
– Mediated by drug use and delinquency during
early and late adolescence
© Cengage Learning 2016
Accompanying Disorders and Symptoms
• Attention-Deficit/Hyperactivity Disorder
– More than 50% of children with CD also have
ADHD
– Possible reasons for overlap
• A shared predisposing vulnerability may lead to
both ADHD and CD
• ADHD may be a catalyst for CD
• ADHD may lead to childhood onset of CD
– Research suggests that CD and ADHD are
distinct disorders
© Cengage Learning 2016
Accompanying Disorders and Symptoms
(cont’d.)
• Depression and anxiety
– About 50% of children with conduct problems
also have depression or anxiety
• ODD best accounts for the connection between
conduct problems and depression
• Increasing severity of antisocial behavior is
associated with increasing severity of depression
and anxiety
• Anxiety may serve as a protective factor to inhibit
aggression
© Cengage Learning 2016
Prevalence
• ODD is more prevalent than CD during
childhood; by adolescence, prevalence is
equal
• Lifetime prevalence rates
– 12% for ODD (13% for males, 11% for
females)
– 8% for CD (9% for males, 6% for females)
• Prevalence for CD and ODD across
cultures of Western countries are similar
© Cengage Learning 2016
Gender
• Gender differences are evident by 2-3
years of age
– During childhood, rates of conduct problems
are about 2-4 times higher in boys
– Boys have earlier age of onset and greater
persistence
– Early symptoms for boys are aggression and
theft; early symptoms for girls are sexual
misbehaviors
© Cengage Learning 2016
Explaining Gender Differences
• Possible explanations
– Genetic, neurobiological, environmental risk
factors, and definitions of conduct problems
that emphasize physical violence
• Girls use indirect, relational forms of
aggression
• Early maturing boys and girls are at risk
for recruitment into delinquent behavior by
peers
© Cengage Learning 2016
General Progression
• Earliest sign is difficult temperament in
infancy
• Hyperactivity and impulsivity during
preschool ad early school years
• Oppositional and aggressive behaviors
peak during preschool years
• Diversification - new forms of antisocial
behavior develop over time
© Cengage Learning 2016
General Progression (cont’d.)
• Covert conduct problems begin during
elementary school
• Problems become more frequent during
adolescence
© Cengage Learning 2016
General Progression (cont’d.)
• Some children break from the traditional
progression
– About 50% of children with early conduct
problems improve
– Some don’t display problems until
adolescence
– Some display persistent low-level antisocial
behavior from childhood/adolescence through
adulthood
© Cengage Learning 2016
Different Forms of Disruptive And Antisocial
Behavior
© Cengage Learning 2016
Two Common Pathways
• Life-course-persistent (LCP) path begins
early and persists into adulthood
– Antisocial behavior begins early
• Subtle neuropsychological deficits heighten
vulnerability to antisocial elements in social
environment
– Complete, spontaneous recovery is rare after
adolescence
– Associated with family history of externalizing
disorders
© Cengage Learning 2016
Two Common Pathways (cont’d.)
• Adolescent-limited (AL) path begins at
puberty and ends in young adulthood
– Less extreme antisocial behavior, less likely to
drop out of school, and have stronger family
ties
– Delinquent activity is often related to
temporary situational factors, especially peer
influences
© Cengage Learning 2016
The Changing Prevalence Of Participation
In Antisocial Behavior Across The Lifespan
© Cengage Learning 2016
Adult Outcomes
• 50% of active offenders decrease by early
20s, and 85% decrease by late 20s
• Negative adult outcomes are seen,
especially for those on the LCP path
– Males - criminal behavior, work problems, and
substance abuse
– Females - depression, suicide, and health
problems
© Cengage Learning 2016
Causes
• Early theories focused on a child’s
aggression
• No single theory explains all forms of
antisocial behavior
• Today conduct problems are seen as
resulting from:
– The interplay among a predisposing child,
family, community, and cultural factors
operating in a transactional fashion over time
© Cengage Learning 2016
Genetic Influences
• Aggressive and antisocial behavior in
humans is universal
– Run in families within and across generations
– Parents pass externalizing behaviors
– Heritability is higher in LCP (life-ling pattern)
– Heritability higher in callous- unemotional style
• Adoption and twin studies
– Indicate 50% or more of variance in antisocial
behavior is hereditary
– Suggest contribution of genetic and
© Cengage Learning 2016
environmental factors
Genetic Risks (cont-d)
Anti-Social Propensity
• Genetic factors may be related to difficult
temperament
• Lack of response to distress in others
(unemotional)
• Impulsivity
• Tendency to seek rewards
• Insensitivity to punishment
• Genetic factors may increase the child sensitivity
to environmental risks such as violence in the
family , divorce, maltreatment
© Cengage Learning 2016
Prenatal Factors and Birth Complications
• Pregnancy and birth factors
– Low birth weight
– Malnutrition (possible protein deficiency)
during pregnancy
– Lead poisoning
– Mother’s use of nicotine, marijuana, and other
substances during pregnancy
– Maternal alcohol use during pregnancy
© Cengage Learning 2016
Neurobiological Factors
• Overactive behavioral activation system (BAS)
and underactive behavioral inhibition system
(BIS)
• Variations in stress-regulating mechanisms
• Structural and functional brain abnormalities in
amygdala, prefrontal cortex, anterior cingulate,
and insula
• Low cortical arousal and low reactivity of the
autonomic nervous system
• This leads to fearlessness, poor response to
punishment
© Cengage Learning 2016
Neurological Factors (cont-d)
• Brain-imaging (fMRI) studies show
reduced activation in brain regions
responsible for emotional processing
• This was found while the youngsters
viewed emotional stimuli such as angry of
sad faces, indicating deficits in processing
social and emotional stimuli
• Such abnormalities underlie the socialemotional deficits seen in children with
conduct disorders
© Cengage Learning 2016
Neurobiological Factors (cont’d.)
• Early findings suggest three neural
systems are involved:
– Subcortical neural systems
• Aggressive behavior - dysfunction in the integrated
functioning of brain circuits involving the amygdala
– Prefrontal cortex
• Decision-making circuits and socioemotional
information processing circuits
– Frontoparietal regions
• Emotions and impulsive motivational urges
© Cengage Learning 2016
Social-Cognitive Factors
•
•
•
•
Immature forms of thinking
Cognitive deficiencies
Cognitive distortions
Deficits in facial expression recognition
and eye contact
• Dodge and Pettit comprehensive socialcognitive framework model
– Cognitive and emotional processes are
mediators
© Cengage Learning 2016
Steps In The Thinking And Behavior Of
Aggressive Children In Social Situations
© Cengage Learning 2016
Family Factors
• Severe forms of antisocial behavior
– Are associated with a combination of child risk
factors and extreme deficits in family
management skills
• Influence of family environment is complex
• Reciprocal influence
– Child’s behavior is influenced by and
influences the behavior of others
• Child behaviors exert greater influence on
parenting behavior than the reverse
© Cengage Learning 2016
Family Factors (cont’d.)
• Coercion theory
– Parent-child interactions provide a training
ground for the development of antisocial
behavior
– Four-step escape-conditioning sequence
• The child learns to use increasingly intense forms
of noxious behavior to avoid unwanted parental
demands (coercive parent-child interaction)
– Children with callous-unemotional traits
display significant conduct problems
regardless of parenting quality
© Cengage Learning 2016
Family Factors (cont’d.)
• Attachment theories
– Children with conduct problems have little
internalization of parent and societal
standards
– There is a relationship between insecure
attachments and the development of
antisocial behavior
© Cengage Learning 2016
Other Family Problems
• Family instability and stress
– High family stress may be both a cause and
an outcome of child’s antisocial behavior
• Unemployment, low SES, multiple family
transitions, instability, and disruptions in parenting
practices are stressors
– Amplifier hypothesis
• Parental criminality and
psychopathology
– Aggressive and antisocial tendencies run
in2016
families within and across generations
© Cengage Learning
Societal Factors
• Individual and family factors interact with
the larger societal and cultural context in
determining conduct problems
• Social disorganization theories
• Adverse contextual factors are associated
with poor parenting
• Neighborhood and school
– Social selection hypothesis
• Media
© Cengage Learning 2016
Cultural Factors
• Across cultures, socialization of children
for aggression is one of the strongest
predictors of aggressive acts
• Rates of antisocial behavior vary widely
across and within cultures
• Antisocial behavior is associated with
minority status in the U.S.
– Likely due to low SES
© Cengage Learning 2016
Treatment and Prevention
• Some treatments are not very effective
– Office-based individual counseling and family
therapy
– Group treatments can worsen the problem
– Restrictive approaches (residential treatment,
inpatient hospitalization, incarceration)
© Cengage Learning 2016
Treatment and Prevention (cont’d.)
• Comprehensive two-pronged approach
includes
– Early intervention/prevention programs
– Ongoing interventions
© Cengage Learning 2016
Effective Treatments For Children With
Conduct Problems
© Cengage Learning 2016
Parent Management Training (PMT)
• Teaches parents to change the child’s
behavior in the home and in other settings
using contingency management
techniques
• Focus is on:
– Improving parent-child interactions
– Promoting positive behavior
– Decreasing antisocial behavior
• Makes numerous demands on parents
© Cengage Learning 2016
Problem-Solving Skills Training (PSST)
• Focuses on cognitive deficiencies and
distortions in interpersonal situations
• Five problem-solving steps are used to:
– Identify thoughts, feelings, and behaviors in
problem social situations
© Cengage Learning 2016
Problem-Solving Skills Training (PSST)
(cont’d.)
• Children learn to:
– Appraise the situation
– Identify self-statements and reactions
– Alter their attributions about others’
motivations
– Learn to be more sensitive to others
© Cengage Learning 2016
Multisystemic Therapy (MST)
• Intensive family- and community-based
approach
– For teens with severe conduct problems who
are at risk for out-of-home placement
• Attempts to empower caregivers to
improve youth and family functioning
• Effective in reducing long-term rates of
criminal behavior
– Reduces association with deviant peers
© Cengage Learning 2016
Preventive Interventions
• Main assumptions
– Conduct problems can be treated more easily
and effectively in younger than older children
– Counteracting risk factors/strengthening
protective factors at young age limits/prevents
escalation of problem behaviors
– Costs to educational, criminal justice, health,
and mental health systems are reduced
© Cengage Learning 2016
Preventive Interventions (cont’d.)
• Incredible Years intensive multifaceted
early-intervention program for parents and
teachers
– Support for effectiveness of early
interventions in reducing later conduct
problems and maintaining positive outcomes
• Fast Track program to prevent
development of antisocial behavior in highrisk children, using five components
© Cengage Learning 2016