Externalizing Disorders
Sahithya BR Assistant Professor
Department of Clinical Psychology, DIMHANS Email: [email protected]
Symptoms of common mental disorders in childhood and adolescence have been conceptually organized into two broad dimensions –
internalizing and externalizing behaviours.
While internalizing dimension has been labelled as overcontrolled or
internalizing, and includes behaviours such as social withdrawal, anxiety, and depression;
Externalizing behaviours are problematic behaviours related to poor
impulse control, impulsivity, and inattention, and include various acting out, disruptive, rule breaking, aggression, delinquent, hyperactive, and aggressive behaviours.
In externalizing dimension, behavioural problems are manifested
in the child/adolescent’s outward behaviour as they negatively
act out on the external environment.
Within the externalizing dimension, there are two major
categories of behavioural problems:
Problems of inattention, impulsivity, and hyperactivity associated with a diagnosis of attention-deficit hyperactivity disorder (ADHD).
Disruptive behavioural problems associated with a diagnosis of oppositional defiant disorder (ODD) or conduct disorder (CD).
ADHD, ODD, and CD are strongly comorbid in child and adolescent samples.
(Atherton, Ferrer & Robins, 2018)
Odds ratios for co-morbid ADHD diagnosis in children diagnosed with ODD/CD ranges from 23.6 to 26.8.
(Fergusson, Horwood and Lynsky, 1994)
Longitudinal research have suggested that ADHD symptoms put youth at risk for developing ODD and early-onset CD symptoms and can
contribute to the developmental progression of oppositional defiant disorder to conduct disorder
Attention deficit hyperactivity disorder
(ADHD)
ADHD, is:
a persistent pattern of inattention and/or hyperactivity-impulsivity, persisted for at least 6 months, and
interferes with functioning or development, with onset prior to age 12,
with several inattentive or hyperactive-impulsive symptoms present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities)
DSM - V
ADHD was moved to the neurodevelopmental disorders chapter to better reflect how brain development correlates with ADHD.
ADHD is no longer classified as a childhood disorder but as a chronic lifelong disorder.
Adult symptom examples have been added to the diagnostic criteria to facilitate diagnosing ADHD across the life span rather than just in childhood.
The age of onset was updated from “symptoms that caused
impairment were present before age 7 years” to “several
inattentive or hyperactive-impulsive symptoms were present prior to age 12”
Inattention
• 6 or more symptoms of inattention for children up to age 16 years, or 5 or more for adolescents age 17 years and older and adults;
• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
• Often has trouble holding attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (loses focus, side-tracked).
• Often has trouble organizing tasks and activities.
• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
• Often loses things necessary for tasks and activities (school materials, pencils, books, wallets, keys, paperwork, eyeglasses, mobile).
• Is often easily distracted
Hyperactivity and Impulsivity
6 or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or 5 or more for adolescents age 17 years and older and adults:
• Often fidgets with or taps hands or feet, or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
• Often unable to play or take part in leisure activities quietly.
• Is often “on the go” acting as if “driven by a motor”. • Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting their turn.
DSM-5 classifies ADHD in three presentations: • Predominantly Inattentive Presentation
• Predominantly Hyperactive-Impulsive Presentation
• Predominately Combined Presentation
DSM-5 classifies the ADHD severity of the present symptoms as “mild,” “moderate,” or “severe.”
Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in only minor functional impairments.
Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.
ICD-10
In ICD-10, the term "hyperkinetic disorder" is adopted rather than ADHD, and inattention, hyperactivity, and impulsivity are listed as separate problem areas, with diagnosis requiring symptoms in all three domains.
However, inattention and hyperactivity are regarded as cardinal features and are emphasized over impulsive symptoms.
Thus, the diagnosis of "hyperkinetic disorder" requires the presence of six of nine symptoms of inattention, three of five hyperactive features, and one of four impulsivity symptoms.
ADHD is the earliest-occurring form of externalizing behaviour and can persist into adolescence and adulthood.
(Beauchaine & Hinshaw, 2015; Davidson, 2008).
Overall ADHD symptoms generally decline over the years.
Symptoms of hyperactivity and impulsivity gradually decrease from childhood to adulthood, whereas, the inattention symptoms persist into adulthood
Population surveys suggest that ADHD occurs in most cultures in about 5% of children and about 2.5% of adults
(Polanczyk & Jensen, 2008)
In India, Prevalence of ADHD is estimated to range from 1.6 to 17.9% in various studies.
(Srinath et al., 2005; Malhotra, Biswas Saran & Grover, 2007)
More recently, Suthar et al. (2018) reported the prevalence of ADHD in school going children to be 5.7%, and it was found to be higher in male children as compare to that of females.
Comorbidities
ADHD is most commonly comorbid with ODD, CD, and learning disorders.
ADHD is specifically linked with poor grades, grade retention, low
academic achievement, problems in executive functioning, and parental inattention and impulsivity. (Kimonis & Frick, 2016; Loe and Feldman, 2007).
Adolescents with ADHD are more likely to have repeated a grade or dropped out of high school, compared to those without ADHD, even after adjusting for social status, IQ, and learning disabilities (Fried et al., 2016)
Higher rates of ADHD reported when anxiety and/or depression were present in the child.
A Complex and Multifaceted Condition
ADHD is a heterogeneous and multifaceted condition involving interplay between diverse systems across multiple levels within the individual.
Various contributing factors, such as genetic influences, neonatal and perinatal insults to the brain, normal
variability of temperament patterns, and environmental risks and protective factors, interact in complex ways to produce the final behavioral outcome in a child.
Genetic Risk Factors
Genetic factors are clearly important in ADHD but little is known about the mechanisms by which their influence is exerted.
Family, adoption and twin studies suggest ADHD is familial and highly heritable
Parents and siblings of ADHD cases display up to an eight-fold
increased risk for ADHD (Faraone & Biederman, 2000) and biological relatives are
more at risk than adoptive family members (Sprich et al., 2000).
According to twin studies, ADHD is amongst the most heritable conditions with estimates between 60 and 90% (Thapar, Harrington, Ross et al., 2000).
Genes regulating neurotransmitter systems have been implicated in ADHD.
An increased rate of large, rare, chromosomal deletions and duplications known as copy number variants have been reported in individuals with ADHD.
However, genetic testing in an individual child is not currently practical in normal clinical practice.
A plausible genetic hypothesis for ADHD is a mixture of dominant and
Gene–environment interactions have been reported for ADHD, and may explain individual differences in response to environmental risk factors. Combinations of polymorphisms in certain genes and environmental
factors may be associated with an increased likelihood of some ADHD symptoms.
Example:
• Dopaminergic genes and maternal smoking, alcohol use or stress during pregnancy, and inconsistent parenting/child self-blame for marital conflict.
Environmental Risk factors
The growing realization of the limitations of the study of genes
in isolation from environments has led to renewed interest in environmental risk in ADHD.
Prenatal Factors
Perinatal Factors
Prenatal Factors
Maternal lifestyle during pregnancy (e.g., smoking and drinking) has been linked to ADHD.
The evidence is strongest for maternal smoking, for which a dose– response relationship with ADHD appears to exist.
The findings for alcohol consumption are less clear-cut if foetal alcohol syndrome is not implicated. (Linnet et al., 2003)
Exposure to cocaine has a range of harmful effects in utero, of which an increased risk of ADHD might be one (Linares et al., 2006).
Maternal stress during pregnancy and associated over secretion of cortisol have been implicated in ADHD.
(Kapoor et al., 2006; O’Connor et al., 2003; Rodriguez & Bohlin, 2005)
Exposure to medication (e.g., benzodiazepines; anticonvulsants) may represent a risk.
But these effects are difficult to disentangle from the effects of the maternal mental illness.
Perinatal Factors
Two-fold increase in ADHD in children born with a very low birth
weight.
(Bhutta et al. 2002)
ADHD children are more likely to have experienced pregnancy
and birth complications.
But these effects are difficult to disentangle from low birth
weight and the increased risk that vulnerable children may be at for a difficult birth.
Postnatal Physical Factors
Social and biological factors appear to have a role in the postnatal
period.
The role of artificial food additives remains controversial but a
randomized controlled trial showed important effects.
(McCann et al., 2007)
Idiosyncratic allergies and intolerances of specific food stuffs are
often identified by parents.
(Aardoom et al., 1997)
A Meta-analysis and a large well-designed trial both suggested small
but significant effects.
Exposure to lead and related neurotoxins may be associated
with a substantially increased risk of inattentive and hyperactive behavior.
But these exposures are both linked to social disadvantage and
cause other nonspecific neurodevelopmental difficulties.
(Levitt, 1999)
Animal models implicate exposure to insecticides, such as DDT,
although a clinical link has yet to be confirmed
(Mariussen & Fonnum, 2006)
Role of dietary deficiencies such as omega-3 fatty acids are also
implicated but require further examination in large-scale trials
Postnatal Social Environment
Chronic exposure to exceptional social environments early on during development can increase the risk for ADHD-like
patterns.
In the English and Romanian Adoptees study, children who
experienced extreme physical, cognitive and social deprivation in infancy were at an increased risk of pervasive and persistent overactivity and inattention despite being adopted into well-resourced and committed homes before the age of 4 years.
Parenting
Claims on parenting in the causes of ADHD are controversial.
Children suffering extreme neglect and abuse may be at increased
risk for ADHD.
(Glod & Teicher, 1996)
However, variation in parenting style within the normal range has been assumed not to play a part.
(Morrell & Murray, 2003).
ADHD can evoke negative and hostile responses from parents.
(Seipp & Johnston, 2005)
Parental characteristics (including adult ADHD symptoms) can moderate these responses and exacerbate coercive cycles.
(Murray & Johnston, 2006)
However, the fact that parent training can significantly reduce core
ADHD symptoms in preschoolers highlights the potential power of the social environment to influence the course of ADHD
Socioeconomic risk factors
A number of international studies have identified socioeconomic
factors associated with development of ADHD symptoms. These include:
• Non-intact family*/single-parent household
• Paternal history of antisocial behavior
• Maternal depression
• Lower maternal education
• Lower social class
• Households of social welfare recipients
• Young maternal age at birth of the target child.
Source: Froehlich, et al., (2011). Update on environmental risk factors for attention-deficit/hyperactivity
Source: Froehlich, et al., (2011). Update on environmental risk factors for attention-deficit/hyperactivity
Neuroanatomy
Based on volumetric and functional MRI studies,
differences are found in the structural development and functional activation in the
prefrontal cortex, basal ganglia,
anterior cingulate cortex, and cerebellum.
Cerebellum
The cerebellum is a brain region that plays a significant role in sensory perception and motor function.
cerebellums of children with ADHD are notably smaller than their non-ADHD peers.
Smaller cerebellum might account for impulsivity - the tendency to act without thinking.
Basal Ganglia
ADHD may affect the basal ganglia connection to the frontal lobe. The basal ganglia are brain structures that help to coordinate motor
control, cognition, emotions, and learning.
caudate and putamen regions within the ganglia are smaller in people with ADHD.
Frontal Lobe
There may be a subset of children with ADHD who have larger frontal
lobes than average.
These children seem to have predominately hyperactive behavior.
Amygdala and Prefrontal Cortex
A smaller amygdala was associated with more severe ADHD symptoms. Poor neural connections between the amygdala and the pre-frontal
cortex.
The pre-frontal cortex influences planning, sequencing, and strategic
behaviors.
This might account for problems with impulsivity; a primary ADHD
Brain Volume
In ADHD patients, reductions in volume have been observed in
total cerebral volume, the prefrontal cortex, anterior temporal
areas the basal ganglia (striatum), the dorsal anterior cingulate cortex, the corpus callosum and the cerebellum.
People with ADHD have brains that are about 4% smaller than
average.
The two brain areas most affected by the size reduction are the
prefrontal cortex, and the anterior temporal areas.
Neuroimaging studies have also reported reduced white matter
volumes, midsagittal corpus callosum areas, and cortical thickness in ADHD patients.
Delayed Maturation
In studies of cortical development in children with ADHD,
a marked delay in brain maturation is seen
The grey matter peaks were about 3 years later than in
healthy controls.
The delay is most prominent in prefrontal regions
important in the control of cognitive processes including attention and motor planning.
Neuropsychology
Quantitative reviews support the association between
ADHD and executive dysfunction across a wide range of domains and measures within domains.
(Huang-Pollock & Nigg, 2003; Lijffijt et al., 2005; Oosterlaan, Logan, & Sergeant, 1998; Willcutt et al., 2005).
Children with ADHD perform worse than controls in
domains such as response inhibition and interference control, planning and working memory.
Source: Nigg, 2009. Retrived from https://www.psychiatrictimes.com/view/cognitive-impairments-found-attention-deficithyperactivity-disorder
Neurotransmitter
Dopamine Individuals with ADHD seem to have an excessively efficient
dopamine-removal system.
They have a higher concentration of dopamine transporters called
re-uptake inhibitors.
When dopamine is removed too quickly, it doesn't have sufficient time to
exert its effect.
Researchers now believe that this overly-efficient transporter process
may help to explain some ADHD symptoms.
Predominantly hyperactivity-impulsive ADHD had changes to their dopamine transport gene, thus affecting dopamine levels in the brain.
Norepinephrine and serotonin.
ADHD symptoms may also be caused by the reduction of two other neurotransmitters: norepinephrine and serotonin.
These neurotransmitters influence brain function in the cerebellum.
Predominantly inattentive ADHD had changes to their
norepinephrine transporter gene, which affects norepinephrine levels in their brains.
Serotonin is another neurotransmitter implicated in ADHD.
It influences mood, social behavior, sleep, and memory. Low levels of serotonin may impair these important functions
A Four-Way Partnership
ADHD seems to involve impaired neurotransmitter activity in four functional regions of the brain:
• Frontal cortex. This region orchestrates high-level functioning: maintaining attention, organization, and executive function. A deficiency of norepinephrine within this brain region might cause inattention, problems with organization, and/or impaired executive functioning.
• Limbic system. This region, located deeper in the brain, regulates our emotions. A
deficiency in this region might result in restlessness, inattention, or emotional volatility. • Basal ganglia. These neural circuits regulate communication within the brain.
Information from all regions of the brain enters the basal ganglia, and is then relayed to the correct sites in the brain. A deficiency in the basal ganglia can cause information to “short-circuit,” resulting in inattention or impulsivity.
• Reticular activating system. This is the major relay system among the many pathways that enter and leave the brain. A deficiency in the RAS can cause inattention,
impulsivity, or hyperactivity.
Goals
(i) Optimizing current functioning across behavioral, academic, family, and social domains by reducing the severity and impact of core and associated symptoms;
(ii) Prevention of the adverse outcomes known to result for many of these youngsters by intensively targeting those problem areas (such as aggression and other antisocial behaviors, academic underachievement or failure, family dysfunction, or peer
Psychosocial Interventions
Parent-based interventions
School-based interventions
Child-based interventions
Parent-based interventions
Parent training (PT) approaches have emerged as the most prevalent psychosocial treatment for the disorder.
Two objectives which characterize PT programs for ADHD are:
educating parents about the disorder and
teaching a comprehensive set of behavior management skills
Parents may act as change agents to reduce negative behavior and promote adaptive functioning in the natural environment.
Efforts are also geared towards improving the general family emotional climate and altering coercive parent - child interactions which may contribute to the
PT programs for ADHD generally rely heavily on therapist modeling, behavior rehearsal (e.g., role playing), and homework and include the following
components:
(i) psychoeducation on ADHD;
(ii) introduction to social learning theory and general behavior management principles;
(iii) positive reinforcement skills (e.g., positive attending, "catch your child being good," promoting independent play, or effective ignoring);
(iv) effective commands;
(v) point or token economy systems;
(vi) nonphysical punishment procedures (e.g., response cost or time out); and
Innovative additions to some recent PT programs have included:
Stress and mood management for parents,
Interventions to enhance marital functioning,
Academic support skills for the home,
Inputs to improve peer functioning, and
Training parents to advocate effectively for their child at school.
Criticism: Despite their documented efficacy for ADHD, PT approaches do not appear to achieve the same magnitude of behavioral effects as pharmacotherapy, typically fail to normalize functioning, and place high demands on parents that can reduce compliance and maintenance of
School-based interventions
Some form of classroom intervention is indicated for children with ADHD due to the adverse impact of inattentive, overactive, impulsive, and associated
symptoms on learning, performance of acquired skills, and adherence to class rules and routines.
School-based treatment for ADHD children may comprise both academic (e.g., tutors or special education services) and behavioral interventions.
A host of classroom interventions for ADHD address antecedents of behavior by making modifications to the classroom environment, materials, and
instructional techniques in an effort to create a "prosthetic" environment that helps to minimize the impact of ADHD symptoms.
Beneficial changes to classroom structure may involve:
establishing clear and salient class rules,
arranging seating so that the child is distanced from likely distracters
and surrounded by well-behaved peers,
instituting highly consistent routines (e.g., for turning in completed
homework), and insisting that students use a daily assignment book.
Students with ADHD often show higher rates of on-task behavior and
task completion through the use of timers, assignments that are shortened or divided into smaller parts, checklists outlining the steps involved in a task, and alternative response methods (e.g., oral reports and videotapes).
Moreover, the effectiveness of instructional methods is likely to be
enhanced when they incorporate higher levels of activity, stimulation, and novelty than is typical for most classrooms.
Contingency management
Manipulating the consequences of behavior.
In direct contingency management approaches, a behavior therapist establishes formal reinforcement systems with clear guidelines for behaviors that both earn and lose tokens, which may subsequently be exchanged for tangible reinforcers (e.g., access to a rewarding classroom computer).
Numerous studies have documented the effectiveness of such methods for improving both academic productivity and classroom behavior
Therapist- Teacher Liaison
Models in which therapists consult with teachers in order to educate them about ADHD and teach effective instructional and behavior management strategies.
Much of the content in such interventions parallels that found in PT, with adaptations to ensure applicability to the school environment.
Thus, teachers learn to make positive attention contingent upon desirable behavior, issue effective commands and reprimands, provide high rates of prompts and feedback, establish token economies specifying individual or group-based contingencies, use response cost and time out as
Child-based interventions
Cognitive-behavioural methods Social skill training
Neurofeedback (EEG Biofeedback) Regular exercise
healthy and varied diet Brain train
Medication
Stimulant medication – usually methylphenidate, Atomoxetine or dexamfetamine – is widely given and licensed for children in many countries.
These three medicines have received extensive trials and systematic reviews.
All three are efficacious in comparisons with placebo.
(Santosh et al., 2005)
Most children whose problems are severe enough to get a diagnosis of hyperkinetic disorder will need medication.
Family attitudes should of course be respected, and often a trial of psychological treatment will be attempted, but medication should be advised if there has been no substantial improvement after a few weeks.
For children at lesser degrees of severity – those who show ADHD but
not hyperkinetic disorder – the choice of initial therapy is more evenly balanced.
In these milder cases there are options about which treatment to start
with.
Decisions will depend on the analysis of the individual child, the
strengths and weaknesses of their school and classroom environment, the severity of disturbance of peer relationships, and the preferences of the families.
It is quite reasonable to start with either therapy, in the knowledge
that one will proceed to the other should the response be suboptimal.
Several prospective studies have followed patients through
adolescence into adulthood.
These studies suggest that a majority of diagnosed young people no
longer meet criteria for ADHD in adult life, but that nevertheless many will still show above-average levels of inattentiveness and impulsivity.
Cross-sectional surveys in adult life come up with surprisingly high
prevalence rates of about 4%. (Kessler et al., 2006) Antisocial behavior tends to persist.
Educational, organizational or occupational failures; substance use
disorders and other dependent, risky, antisocial or illegal behaviors; or emotional and relationship difficulties are also prevalent. (Millstein et al., 1998)
Any questions or inputs
on
Oppositional defiant disorder :
is defined as a recurrent pattern of negativistic,
defiant, disobedient and hostile behaviors leading to impairment of day to day activities.
Generally, the onset of symptoms is prior to age 10, but the prevalence rates of oppositional defiant disorder symptoms increase into adolescence.
DSM V criteria: Disruptive, Impulse-Control, and Conduct Disorders
A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at
least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.
Angry/Irritable Mood
1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.
Argumentative/Defiant Behavior
4. Often argues with authority figures or, for children and adolescents, with adults.
5. Often actively defies or refuses to comply with requests from authority figures or with
rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior.
Vindictiveness
B. The disturbance in behavior is associated with distress in the individual
or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational,
occupational, or other important areas of functioning.
C. The behaviors do not occur exclusively during the course of a psychotic,
substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.
Specify current severity:
Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers).
Moderate: Some symptoms are present in at least two settings. Severe: Some symptoms are present in three or more settings.
ICD 10
F90 - F98 Behavioral and emotional disorders with onset usually occurring in
childhood and adolescence.
F91 Conduct disorders.
The disorder requires that the overall criteria for conduct disorder to
be met.
Usually occurring in younger children,
Primarily characterized by markedly defiant, disobedient, disruptive
behavior that does not include delinquent acts or the more extreme forms of aggressive or dissocial behavior.
The key to distinguishing ODD from other types of conduct disorders is
the absence of behaviors that violate the law and the basic rights of others.
Prevalence
In US, Point prevalence estimates of oppositional defiant disorder range from 2 to 16 percent. (Merikangas et al., 2010)
In India, it was estimated to be 7.73%. (Mishra, Garg & Desai, 2014)
Longitudinal research has documented gradual decreases or no change in oppositional defiant disorder from childhood through adolescence.
(Tremblay et al., 2013; van Lier, van der Ende, Koot, & Verhulst, 2007)
While, the irritability and emotional dysregulation persists into adulthood, the defiance behaviour may decline over the years.
(Leadbeater & Homel, 2015)
Oppositional defiant disorder can be seen as precursor to the development of conduct disorder.
Conduct disorder are characterized by
a recurring and persistent pattern of antisocial behavior involving the violation of others' basic rights and major societal norms or rules.
Some youth manifest conduct disorder in terms of overt aggressive
and hostile acts towards others,
while other youth show a pattern of covert, deceitful acts (e.g.,
stealing, lying, truancy) without accompanying interpersonal aggression,
still others show a combination of these two patterns of antisocial
DSM V:
A. A repetitive and persistent pattern of behavior in which the basic rights of
others or major age appropriate societal norms or rules are violated, as
manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others. 2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others (e.g., a
bat, brick, broken bottle, knife, gun).
4. Has been physically cruel to people. 5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery).
Destruction of Property
8. Has deliberately engaged in fire setting with the intention of causing serious
damage.
9. Has deliberately destroyed others’ property (other than by fire setting).
Deceitfulness or Theft
10. Has broken into someone else’s house, building, or car.
11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons”
others).
12. Has stolen items of nontrivial value without confronting a victim (e.g.,
shoplifting, but without breaking and entering; forgery).
Serious Violations of Rules
13. Often stays out at night despite parental prohibitions, beginning before age 13
years.
14. Has run away from home overnight at least twice while living in the parental
or parental surrogate home, or once without returning for a lengthy period.
B. The disturbance in behavior causes clinically significant
impairment in social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met
for antisocial personality disorder.
Specify whether:
Childhood-onset type: Individuals show at least one
symptom characteristic of conduct disorder prior to age 10 years.
Adolescent-onset type: Individuals show no symptom
characteristic of conduct disorder prior to age 10 years.
Unspecified onset: Criteria for diagnosis of conduct disorder
are met, but not enough information available to determine whether the onset of the first symptom was before or after age 10 years.
Specify if:
With limited prosocial emotions: To qualify for this specifier, an
individual must have displayed at least two of the following
characteristics persistently over at least 12 months and in multiple relationships and settings.
Lack of remorse or guilt: Does not feel bad or guilty when he or she does
something wrong (exclude remorse when expressed only when caught and/or facing punishment).
Callous—lack of empathy: Disregards and is unconcerned about the
feelings of others. The individual is described as cold and uncaring.
Unconcerned about performance: Does not show concern about
poor/problematic performance at school, at work, or in other important activities.
Shallow or deficient affect: Does not express feelings or show emotions
to others, except in ways that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed) or when emotional expressions are used for gain.
Specify current severity:
Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause
relatively minor harm to others (e.g., lying, truancy, staying out after dark without permission, other rule breaking).
Moderate: The number of conduct problems and the effect on others intermediate between those specified in “mild” and those in
“severe” (e.g., stealing without confronting a victim, vandalism). Severe: Many conduct problems in excess of those required to make
the diagnosis are present, or conduct problems cause considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering).
ICD 10
Conduct disorders are characterized by a repetitive and
persistent pattern of dissocial, aggressive, or defiant conduct. Such behavior, when at its most extreme for the individual,
should amount to major violations of age-appropriate social expectations, and is therefore more severe than ordinary childish mischief or adolescent rebelliousness.
Isolated dissocial or criminal acts are not in themselves
grounds for the diagnosis, which implies an enduring pattern of behavior.
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 to property;
fire-setting;
stealing;
repeated lying;
truancy from school and running away from home;
unusually frequent and severe temper tantrums;
defiant provocative behaviour; and
persistent severe disobedience.
Any one of these categories, if marked, is sufficient for the
ICD-10 identifies different subtypes.
Conduct disorder confined to the family context.
dissocial or aggressive behavior in which the abnormal behaviour is
entirely, or almost entirely, confined to the home and/or to interactions with members of the nuclear family or immediate household.
Unsocialized conduct disorder
This type of conduct disorder is characterized by the combination of
persistent dissocial or aggressive behaviour with a significant pervasive abnormality in the individual's relationships with other children.
Disturbed peer relationships are evidenced chiefly by isolation from
and/or rejection by or unpopularity with other children, and by a lack of close friends or of lasting empathic, reciprocal relationships with others in the same age group.
Relationships with adults tend to be marked by discord, hostility, and
Socialized conduct disorder
This category applies to conduct disorders involving persistent dissocial or aggressive behavior occurring in individuals who are generally well
integrated into their peer group.
The key differentiating feature is the presence of adequate, lasting friendships with others of roughly the same age.
Often, the peer group will consist of other youngsters involved in delinquent or dissocial activities (in which case the child's socially unacceptable conduct may well be approved by the peer group and regulated by the subculture to which it belongs).
This is not a necessary requirement for the diagnosis: the child may form part of a non-delinquent peer group with his or her dissocial behavior taking place outside this context.
If the dissocial behavior involves bullying in particular, there may be disturbed relationships with victims or some other children.
Mixed disorders of conduct and emotions
This group of disorders is characterized by the combination of persistently
aggressive, dissocial, or defiant behavior with overt and marked symptoms of depression, anxiety, or other emotional upsets.
Depressive conduct disorder
This category requires the combination of CD with persistent and marked
depression of mood (symptoms such as excessive misery, loss of interest and pleasure in usual activities, self-blame, and hopelessness.)
Disturbances of sleep or appetite may also be present. Other mixed disorders of conduct and emotions
This category requires the combination of CD with persistent and marked
emotional symptoms such as anxiety, fearfulness, obsessions or compulsions, depersonalization or derealization, phobias, or hypochondriasis.
Anger and resentment are features of conduct disorder rather than of emotional
Prevalence
Estimates of the prevalence of conduct problems vary according to the
criteria used.
On the basis of the majority of epidemiological studies from the
industrialized west, 5–10% of children and adolescents have significant persistent oppositional, disruptive or aggressive behavior problems. (Angold & Costello, 2001; Green et al., 2005)
The worldwide prevalence rates of conduct disorder is estimated to be 3.6% and 1.5% in males and females respectively. (Erskine et al., 2014; Salmanian, Mohammadi, Keshavarzi & Brand, 2018)
Mishra, Garg & Desai, (2014) reported prevalence of conduct disorder to be 5.48% with higher prevalence among the males than females.
Gender difference
Higher prevalence among males.
Males exceed females in the frequency and severity of behaviors. Studies report that the individual and family factors associated with
self-reported delinquency were the same for males and females, but were more common in males. (Rowe, Vazsonyi, & Flannery, 1995; Moffitt et al., 2001)
Reviews of twin studies have revealed no systematic differences
between the sexes in the contributions of genetic and environmental factors. (Rhee & Waldman, 2002)
The causes of conduct problems are the same for the sexes, but males
have more conduct disorder because they experience more of its
individual-level risk factors (e.g., hyperactivity, neurodevelopmental delays).
Comorbidity
More than 90% of individuals having conduct or antisocial personality disorder also meet diagnostic criteria for other disorders.(Moffitt et al., 2001; Robins & Regier, 1991)
Conduct disorder has been shown to feature prominently in the developmental history of virtually every adult
psychiatric disorder, including schizophrenia and eating disorders. (Kim-Cohen et al., 2003)
A meta-analysis of associations among child psychiatric disorders
estimated the odds ratio for ADHD in the presence of conduct disorder is 10.7. (Angold, Costello, & Erkanli, 1999)
Children who have both ODD/CD and ADHD have
more varied and severe ODD/CD symptoms,
greater levels of parental psychopathology,
more conflictual interactions with parents,
greater peer problems,
school difficulties and psychosocial adversity,
worse neuropsychological deficits and poorer prognosis into
adulthood. (Angold, Costello, & Erkanli, 1999; Lynam, 1996)
Twin studies suggest a common genetic component underlying
Other disorders most consistently implicated are adolescent
depression and substance abuse.
Conduct problems and the co-occurring disorder grows stronger
with age, becoming more marked in adolescence.
Diagnoses of learning disabilities and reading impairment are also
highly prevalent among children with conduct problems. (Carroll et al., 2005)
When conduct disorder is diagnosed, any co-occuring behavioral
or learning disorders should also be ascertained, as these may afford an opportunity for prevention.
The symptoms usually emerge in childhood and can either be confined to
adolescence or can persist in to adulthood, however, not all youth with childhood-onset conduct disorder exhibit a life-course persistent pathway. (Moffitt, 2006)
Children with conduct disorder are more likely to grow up to become delinquent as adolescents, and criminal and violent as adults. (Farrington, 1997)
Conduct disorder in early life has been found to be not only associated with
significant decline in educational performance, but they are more likely to remain socially isolated with increase in substance misuse during adolescence. (Ghosh, Malhotra & Basu, 2016).
There is increase involvement in criminal acts resulting in frequent contact with the criminal justice system. (Sagar, Patra & Patil, 2019)
This adverse effect continues even in adult life with resulting poorer educational and occupational outcomes.
It is still not known what exactly causes conduct disorder, but it is a
commonly held belief that it is a combination of genetic, environmental, and psychosocial factors
Some of the main categories of risk for CD include
Genetic
Biological
Neurological
Perinatal Complications
Temperament,
Parental and Familial factors,
Exposure to Adult Marital Conflict and Domestic Violence
Family Poverty
Maltreatment
Risks in Neighborhood
Genetic
• Various studies indicate a moderate degree of heritability for antisocial behavior, impulsivity, and aggression.
• One genome-wide linkage study identified chromosomal
regions that are good bets for harboring 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
• 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. (Caspi et al., 2002)
• Positive and negative replication studies have appeared, 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)
Biological
• Evidence for low levels of plasma dopamine beta-hydroxylase supports the finding of decreased activity of the noradrenergic system in the CD.
• Low levels of 5-Hydroxy Indole acetic acid (5-HIAA) levels in CSF correlates with aggression and violence in adolescence.
• High testosterone levels are also associated with aggression.
• Pittsburgh youth cohort: Boys with long-standing 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, other studies have failed to find an association
between conduct disorder and measures of norepinephrine in children. (Hill, 2002)
• Some limited evidence supports the view that, as in adults, serotonin is linked with aggression in children, but findings for indices of serotonin function in children are also markedly
Neurological
• Some studies suggest a correlation between resting frontal brain electrical activity (EEG) and aggression in children.
• Neuropsychological insults to the brain in early life can cause deficits in language, memory, and executive functioning leading to poor judgment and inability to plan and problem solve in crisis situations.
• Developmental delays causes poor social skills, learning disability, below average intellectual capacity, thus contributing to difficulties in learning,
academic difficulties, low self-esteem and tendency for children to engage in disruptive behaviors
• Any traumatic brain injury, seizures, and neurological damage can contribute to aggression.
Children with conduct problems have been shown consistently to have increased rates of deficits in language-based verbal skills (Lynam & Henry, 2001; Nigg & Huang-Pollock, 2003).
Conduct-disordered children, delinquent adolescents and adult
antisocial individuals show poor performance on standardized tests of verbal ability, and in tests of IQ, poor verbal and performance scores.
These associations hold after controlling for potential confounds such as
race, socioeconomic status, academic attainment and test motivation.
(Lynam, Moffitt, & Stouthamer-Loeber, 1993)
Longitudinal studies show that persistence in antisocial behavior over
periods of years is predicted by low verbal IQ in childhood. (Farrington & Hawkins, 1991; Lahey et al., 1995; Lynam & Henry, 2001)
Children and adolescents with conduct problems have been shown consistently to have poor tested executive functions. (Ishikawa & Raine, 2003; Lynam & Henry, 2001; Moffitt, 1993b; Nigg & Huang-Pollock, 2003)
Perinatal Complications
Birth complications might be a contributory factor to
neuropsychological deficits that are associated with conduct problems. (Moffitt, 1993b)
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 birth weight. (Brennan, Grekin, & Mednick, 2003)
Smoking in pregnancy is a statistical risk predictor of offspring conduct problems. (Brennan, Grekin, & Mednick, 2003)
But a causal link between smoking and conduct problems has not
Temperament
Although there is tremendous variability in developmental outcome, toddlers who show difficult temperaments are at heightened risk of developing
conduct problems at school entry which might escalate over time.(Campbell, 1991; Campbell, Breaux, Ewing, & Szumowski, 1986).
Young children who exhibit greater impulsivity, emotional lability, and
irritability than their agemates often face adverse environmental reactions if their behavioral style persists through early childhood.
Several prospective studies have shown associations between temperament and conduct problems, (Keenan & Shaw, 2003)
and also predicted antisocial personality disorder and criminal offending into adulthood. (Caspi, Moffitt, Newman et al., 1996)
Parental and Familial factors
Temperament difficulties do not typically persist or escalate independent of environmental context.
Here is where familial risk factors may operate to potentiate temperamental risk.
A home environment that lacks structure and adequate supervision with
frequent marital conflicts between parents, inconsistent discipline lead
to maladaptive behavior.
• Harsh parenting with verbal and physical aggression towards children.
• Children exposed to frequent domestic violence.
• The family history of criminality and disruptive behaviors in caregivers.
Living in low social, economic conditions with overcrowding and
unemployment lead to economic and social stress with lack of adequate parenting.
Patterson’s Model (1982)
parents of antisocial children are more inconsistent in their use of
rules; to issue more, and unclear, commands; to be more likely to respond to their children on the basis of mood rather than the
characteristics of the child’s behavior; to be less likely to monitor their children’s whereabouts; and to be unresponsive to their
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 a
prohibition.
The child responds by escalating his/her behavior.
Mutual escalation continues until the parent backs off. Thus negatively reinforcing the child’s behavior.
The parent’s inconsistent behavior increases the likelihood of
the child showing further oppositional or aggressive behavior.
Children’s difficult behaviors do evoke parental negativity. Adoption studies have shown that adoptees at genetic risk of
antisocial disorders are more likely than low-risk children to evoke negative parenting in the adoptive home. (Ge et al., 1996; O’Connor et al., 1998)
Exposure to Adult Marital Conflict and
Domestic Violence
Children exposed to domestic violence between adults are subsequently
more likely to become aggressive themselves. (Moffitt & Caspi, 1998)
Marital conflict influences children’s behavior because of its effect on their
regulation of emotion. (Davies and Cummings, 1994)
Children are likely to imitate aggressive behavior modeled 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
Family Poverty
There is an association between severe poverty and early childhood
conduct problems (Farrington & Loeber, 1998).
Early theories proposed direct effects of poverty related to strains
arising from the gap between aspirations and realities, and from 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 and parenting deficits (Maughan, 2001)
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., 1994)
Another study took advantage of a naturally occurring experiment.
(Costello et al., 2003)
Native American families in North Carolina, formerly living below
the poverty line, benefitted from increased income from newly opened casinos.
In many families, the children’s behavior problems decreased
markedly as a result.
However, the effect of increased income was mediated through
Maltreatment
Associations between physical abuse and conduct problems
are well established. (Hill, 2002)
Christchurch cohort study: Child sexual abuse predicted
conduct problems, after controlling for other childhood adversities. (Ferguson, Horwood, & Lynskey, 1996)
In a large prospective study of court substantiated cases of
abuse and neglect,
26% of abused and neglected adolescents were antisocial,
contrasted with 17% in a well-matched comparison group,
implying a modest but long-lasting effect of abuse and neglect.
Risks in the Neighbourhood
Bad neighborhoods may have the effect of encouraging children
to develop conduct problems.
New research suggests that the neighborhood factors that are
important go beyond structural demographic characteristics.
Neighborhood-level social processes such as “collective efficacy”
and “social control” do influence young children’s conduct
problems, probably by supporting or failing to support parents in their efforts to rear children.
Peer Influences
Children with conduct problems have poorer peer relationships than
non-disordered children in that
they tend to associate with children with similar antisocial behaviors,
they have discordant interactions with other children and experience
rejection by non-deviant peers. (Vitaro, Tremblay, & Bukowski, 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 behaviors,
Peer rejection has been shown to contribute to declines in academic
achievement and increases in aggression across the first year of primary schooling. (Coie, 2004)
One consequence of rejection by healthy peers is that from as young
as 5 years aggressive-antisocial children are obliged to associate with other deviant children. (Farver, 1996; Fergusson, Woodward, & Horwood, 1999)
Youth who are aggressive are attracted to each other, and deviant
youth reinforce each others’ antisocial behaviors and attitudes. (Boivin & Vitaro, 1995)
A natural experiment study tracked change in antisocial behavior
among boys who joined a gang.
Joining a gang increased each adolescent’s individual offending over his
pre-gang baseline,
whereas leaving the gang decreased each individual’s personal offending
Psychosocial Treatments
Parent management training with the goal to train parents to set consistent discipline with proper rewarding of positive behaviors and promote prosocial behaviors in
children.
Set of principles and goals:
(i) Parent trainers help parents pinpoint, and then monitor, specific positive and negative behaviors that they want to change.
(ii) Positive reinforcement is emphasized as more important than punishment. (iii) Parents are encouraged to replace corporal punishment with time-out from
(iv) The principle of shaping is promoted as a strategy for starting with children's existing behavioral repertoires and expanding their capabilities.
(v) Systematic attending and ignoring are key parenting skills that are particularly effective with younger children.
(vi) Many of the parent training programs emphasize positive communications by parents to motivate children and strengthen family relationships.
(vii) Programs attempt to increase the probability of positive parental attention for child prosocial behaviors (e.g., cooperation, calm talking, appropriate play behavior, sharing, complying with adult requests, staying out of fights).
(vii) assist parents in coping more effectively with child antisocial, aggressive, and noncompliant behaviors.
Family Therapy
In contrast to parent training in which the therapist works primarily with the parents, family
therapy involves at least the parent(s) and adolescent plus other members of the household such as siblings and extended family.
Some of the more prominent family therapy approaches include structural family therapy, functional family therapy, and behavioral family therapy.
Although adopting somewhat varied tactics, these three therapy approaches share in common the recognition that youth antisocial behavior is bound up to some degree in family
interactions.
These approaches all attempt to help families attain their goals and improve relationships and communication within the family.
Multisystemic therapies
Multisystemic therapy - is a hybrid of traditional family therapy and behavior
therapy with a strong emphasis on ecological context.
The therapist works with the family and the youth in the home and elsewhere to
alter systemic processes known to be related to antisocial behavior.
Therapists address parental discipline, family communication and affect, peer
associations, school issues, and other potentially significant domains in the larger contexts in which the youth operates.
Multisystemic therapy targets family, school, individual, with a focus on
improving family dynamics, academic functioning and improving the child’s behavior in the context of multiple systems
Individual psychotherapy
Individual psychotherapy targets developing problem-solving skills, strengthen
relationships, resolving interpersonal conflicts, learn assertive skills to decline negative influences in the community.
Therapies can have several targets:
1 To reduce children’s aggressive behavior such as shouting, pushing and arguing.
2 To increase prosocial interactions such as entering a group, starting a conversation,
participating in group activities, sharing, cooperating, asking questions politely, listening and negotiating.
3 To correct the cognitive deficiencies, distortions and inaccurate self-evaluation
exhibited by many of these children.
4 To ameliorate emotional regulation and self-control problems so as to reduce
emotional lability, impulsivity and explosiveness, enabling the child to be more reflective and able to consider how best to respond in provoking situations.
While child CBT was originally mainly used with school-age children and older,
more recently it has been successfully adapted for preschoolers.
These interventions may be delivered in individual or group therapy formats.
Youth-focused treatments for CD include social skills training, problem-solving
training, self-control training, anger management, or some combination of these.
Social-skills approaches typically include individual and group reinforcement,
coaching and shaping of specific interpersonal behaviors, positive group activities, friendship skills, and listening/speaking skills.
Other approaches have combined interpersonal problem-solving and
self-instruction (self-talk) in an effort to alter the cognitive bases assumed to underlie conduct problems.
Interventions in School
Typically, teachers are taught techniques that they can apply to all children in their class as well as to those exhibiting the most antisocial behavior.
Successful approaches use proactive strategies and include a focus on positive behavior and group interventions, and combine effective
instructional strategies with effective behavioral management. Typically, they target four areas of functioning:
1 Promote positive behaviors such as compliance and following established classroom rules and procedures.
2 Prevent problem behaviors such as talking at inappropriate times and fighting.
3 Teach social and emotional skills such as conflict resolution and problem-solving.
Establishing and teaching rules and procedures involves setting rules such as “use a quiet voice,” “listen when others are speaking,” “keep your hands and feet to yourself” and “use respectful words.”
These rules are all expressed positively, describing what the child should do, rather than as prohibitions stating what they should not do.
Streipling (1997) offers six “rules for making rules”: 1 Make few rules (3–6).
2 Negotiate them with the children.
3 State them behaviorally and positively.
4 Make a contract with the children to adhere to them. 5 Post them in the classroom.
Crucial to all this is a systematic and consistent response to children following or not following the rules.
Rewards can be social (teacher praise, peer recognition, notes home to parents), material (stickers, certificates,
tokens to exchange for food, etc.), or privileges (e.g., extra breaktime, games, parties, computer time).
Mild punishments include reprimands, response-costs
procedures (losing privileges or points) and time out (being sent to the corner of the room or to another boring place).
Community-based treatment
Therapeutic schools and residential treatment centers that can provide a structured program to reduce disruptive behaviors.
Community prevention program involves several program interventions such as teacher training, child social and emotional skill development, and parental training targeted in high risk communities.
(Hawkins et al., 2012)
School-community-university partnership - interventions are implemented based on the specific needs of the school or community. (Spoth et al., 2007)
The purpose of this program is to link university-based prevention researchers to elementary and secondary school personnel such as counsellors, principals, etc., and community providers of youth services, to implement the most efficacious prevention strategy given the school’s needs. In consultation with researchers, school personnel select from a menu of prevention programs that
fit best with their overall goals and populations including school-based and parenting interventions.
The effect sizes for these prevention and intervention programs were generally small to moderate.
Pharmacotherapy
• At present, there are no pharmacological interventions approved specifically for conduct disorder.
• Treating psychiatric comorbidities with appropriate medications such as: • stimulants and non-stimulants for the treatment of ADHD,
• antidepressants for the treatment of depression,
• mood stabilizers for the treatment of aggression, mood dysregulation, and bipolar
disorder.
• The best-studied pharmacological interventions for youth with conduct
problems are psychostimulants (methylphenidate and dexamfetamine), as used with children with comorbid ADHD and conduct disorder.
• There is evidence that reduction in hyperactivity-impulsivity will also result in reduced conduct problems. (Connor, Glatt, Lopez et al., 2002; Gerardin, Cohen, Mazet et al., 2002)
