Conduct Disorder

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Conduct Disorder

Conduct disorder (CD) refers to a broad spectrum of potentially enduring behaviors that violate social norms. The behaviors and symptoms of CD vary, with diagnostic criteria clustered into one of four broad categories: (a) aggressive behavior; (b) nonaggressive misbehavior; (c) deceitfulness or theft; and (d) a serious infraction of established rules.

Aggressive conduct is that which threatens or causes physical harm to people or animals and typically involves acts such as initiating fights, bullying, intimidating, overt aggression, and physical cruelty. Nonaggressive conduct is characterized by vandalism or intentional destruction of property. Common manifestations of deceitfulness include stealing, persistent lying, and fraudulent behavior. Lastly, rule violation entails deeds that defy or circumvent social convention. The severity of observed behaviors is rated as mild, moderate, or severe, depending upon the number and seriousness of acts committed and the extent to which others are harmed.

Reported rates of the disorder have increased over several decades, with 6 to 16 percent of males and 2 to 9 percent of females under the age of 18 fulfilling diagnostic criteria (American Psychiatric Association 1994). These results are generally consistent across cultures. Epidemiological data indicate that the prevalence rates for CD are generally greater for males than females. However, some researchers are concerned that the current diagnostic protocol overemphasizes behaviors that are more typical of male than female problem behavior.

To receive a diagnosis of CD, three or more behaviors in any of the four categories must occur within the last twelve months, with at least one of these behaviors persisting during the previous six months. Noncompliance with adults (parents, teachers, or both) typically marks the beginning of a behavior pattern that often culminates in the youth engaging in acts consistent with CD. In general, the early onset of problem behavior in multiple settings and variability of observed problem behavior are associated with more serious psychosocial disruption, escalation to more serious problem behaviors in adolescence (Loeber and Dishion 1983), and ultimately, continuity of adjustment problems into adulthood (e.g., antisocial personality disorder, chronic offending, substance use, marital problems, employment difficulties).

Children and adolescents diagnosed with CD also tend to suffer from elevated rates of hyperactivity and emotional difficulties. Many individuals with behavior problems experience clinical levels of attention deficit hyperactivity disorder (ADHD), depression, and anxiety. Research suggests that youth with both ADHD and CD experience high levels of peer rejection, academic problems, psychosocial hardship, conflict with parents, and parental psychopathology (see Angold and Costello 2001, for a review). The prognosis for persons with both ADHD and behavioral maladjustment also tends to be worse than for those with either diagnosis alone. Combined with depression, CD is generally a marker for more severe psychosocial disruption and heightens the risk for suicide and other adjustment problems in young adulthood. Children with CD often do not simply outgrow their problem behavior (Robins 1966).

A Model of Conduct Problems

Given the magnitude and breadth of difficulties experienced by children fitting the CD diagnosis, coupled with the costs of adolescent problem behavior to families, community, and society, there have been hundreds of studies of CD. Findings from carefully controlled intervention research combined with those of longitudinal investigations provide the best evidence of causality and offer suggestions regarding promising intervention strategies. Figure 1 summarizes a model that synthesizes the results of a several longitudinal and intervention studies.

A crucial issue that emerges from research on child and adolescent socialization is that the development of a behavioral repertoire is determined by a variety of interrelated factors. Multidirectional transactions between child genes, family environment, and the broader social and cultural ecology create a history of experience through which anti-social behavior is successively manifested and reinforced. Figure 1 illustrates this complexity, with bold arrows indicating effects demonstrated in both longitudinal and experimental intervention research.

Biological Factors

Certain neuropsychological indicators (influences in the brain that are linked to psychological functioning) are linked with aggression. Aggression and impulsiveness are associated with structural abnormalities related to thought processing and inhibition of behavior. Deficits in certain neurochemicals, including serotonin and norepinephrine, are also linked to behavior problems. Reductions in the functioning of the autonomic nervous system, which is responsible for the regulation of bodily processes, is also linked to chronic conduct problems. In particular, low-resting heart rate and low-skin conductance are frequently present in individuals with persistent behavior problems. These deficits and resultant reductions in behavioral inhibition are characteristic of both CD and ADHD.

Contemporary theories accentuate a dynamic interplay between biological and environmental factors and propose that most of the effects of a person's biological constitution on CD are mediated through disrupted parenting and peer environments (Deater-Deckard and Bullock, in press). There is some evidence that child-onset CD, characterized by antisocial behavior and hyperactivity, may have stronger biological underpinnings than later-onset CD. Exploration of reciprocal transactions between genes and the environment suggests that children may evoke reactions from parents and others that contribute to antisocial behavior (Rutter et al. 1997).

Individual differences in infant temperament are also directly implicated in behavioral development, with mothers' ratings of children's difficult and hyperpersistent temperament at six months predicting later teacher ratings of conduct difficulties. Studies of adoptees at genetic risk for conduct problems also indicate that genetically compromised children are more likely to experience harsh, negative parenting in their adoptive families, compared to children without a liability for problem behavior (Ge et al. 1996).

Some theorists propose that individuals actively select environments and relationships consistent with their genetic disposition (Scarr and McCartney 1983), with antisocial youth selecting peers who reinforce deviance. Although little research focuses on the biological characteristics that contribute to the influence of deviant peers in early adolescence, the ability of individuals to regulate their behavior and emotions seems to be a promising candidate. Many other biologically oriented constructs have been proposed, but none have clarified whether such constructs are causally unique or simply by-products of being raised in a harsh family environment from an early age.

Family Management

Parenting behavior is also mediated by genetic influence. Individuals prone to aggression, impulsiveness, and antisocial acts are more inclined to create harmful rearing environments characterized by harsh parenting, hostile relationships, and little supervision. Inconsistent harsh discipline, insufficient monitoring, coercive parenting, and child abuse and neglect have long been associated with child-conduct problems and adult criminal behavior.

Parental behaviors directed to one or more siblings may further contribute to the development of deviance. A recent investigation of differential parenting and adjustment revealed that parent-directed behaviors toward each sibling were strongly correlated with individual levels of adolescent problem behavior. Youths with a negatively treated sibling had better outcomes, suggesting that harsh behavior directed toward a fellow sibling may serve a protective function (O'Connor, Hetherington, and Reiss 1998). These findings suggest that children's interpretation of the dynamics of their rearing environment influences the manner in which they respond to future parent attempts to socialize.

Parent behavior may vary greatly for individuals of different ethnic or cultural backgrounds. Physical discipline is known to exert a differential impact on outcomes for European-American children in contrast to their African-American counterparts (Deater-Deckard et al. 1996). A recent report suggests that physical discipline is associated with higher scores of conduct problems only among European-American children. It is hypothesized that physical discipline may be perceived as being more normative and less destructive or deviant by African-American children. Thus, the effectiveness of particular parenting techniques may be mediated by cultural factors and universal statements regarding parenting behavior are ill advised.

Peer Deviance

As development progresses, children become more involved in choosing and shaping their environments. In particular, adolescents are more active in shaping the constituency of their peer environment, and unfortunately may select settings with greater prevalence of problem behavior and substance use. Parent involvement and monitoring of adolescent activities can be an important counteractive force in the drift to deviant peers.

Evidence is compelling that the peer group can cause escalations in drug use, delinquency, and violent behavior in adolescence (Dishion, Spracklen, and Andrews 1996). Problem behavior becomes a mechanism for making friends and eventually in selecting relationship partners with similar values. When peers encourage deviance, youngsters may become especially difficult to monitor and display more resistance to parenting efforts.

Contextual Influences

An ecological framework for understanding development promotes research linking contextual influences with basic socialization processes in the emergence of competence and dysfunction (Bronfenbrenner 1989). Child relationships with teachers and other school officials, as well as influences that arise from factors including poverty and social disadvantage, all interact to create an intricate developmental tapestry that potentially supports maladaptive behavior.

Contextual conditions that can affect the development of antisocial behavior include divorce, marital transitions, poverty, and unemployment. Consistent with an ecological emphasis, it seems that these factors influence CD by disrupting family and peer environments. In a classic study, Glen Elder, Tri Van Nguyen, and Avshalom Caspi (1985) showed that poverty associated with the Great Depression disrupted parent-child interactions and was a factor in behavior problems in children.

For some children, the climate at school is reminiscent of their own family context in that relationships with teachers and peers can be experienced as conflictual, coercive, and embedded in spirals of negative interactions. This elevates the likelihood of child disengagement from the learning process. Academic failure is well documented to be strongly linked to aggressive, impulsive, antisocial behavior and criminality. In addition, studies of school environments suggest that classroom aggression may also influence the development of conduct problems. A study of first grade children revealed that individually aggressive boys in highly aggressive classes are at increased risk of being rated aggressive by sixth grade teachers (Kellam et al. 1998), confirming that experiences across multiple domains influence the development of conduct problems.

Cross-Cultural Research

Comprehensive reviews of the literature on the development of antisocial behavior and conduct problems suggest that prevalence and incidence is highest among children and adolescents within the United States (Dishion, French, and Patterson 1995). However, several longitudinal studies have been conducted outside of the United States that are integral to the development of theory, for example, in London (West and Farrington 1977), Finland (Pulkkinen 1996), Norway (Olweus 1979), New Zealand (Fergusson and Horwood 2002), and Sweden (Stattin and Magnusson 1991). Although prevalence rates vary, the major models of etiology, symptom clustering, stability, and longitudinal course over the lifetime show a high level of convergence across international contexts.

Implications for Treatment

The pioneering work of Gerald Patterson, Rex Forehand, and Bob Wahler brought family management to the fore as a critical component of systematic parent-training programs. These programs often produced observable changes in parenting strategies, which, in turn, positively affected child behavior. Interventions that improve school organization and support teachers' proactive behavior management also show promise in preventing antisocial behaviors at school, which are highly relevant to CD.

In general, interventions that encourage adults to manage the family context, promote prosocial classroom norms, and foster proactive supervision of school behavior generate reductions in antisocial behavior. Reviewers of the treatment literature on CD concur that interventions emphasizing family management practices are among the most effective strategies to date (Kazdin 1993).

Intervention research also addresses the power of the peer group in contributing to CD. Random assignment studies show that treatments that combine youth into groups lead to escalations in drug use, increased problem behavior at school, and long-term negativity. In one study, assignment of high-risk children to summer camps was associated with a ten-fold increase in risk for thirty-year negative outcomes (Dishion, McCord, and Poulin 1999). Treatment strategies that combine high-risk youth run the risk of exacerbating the problem behavior, with less-supervised intervention groups being more likely to produce iatrogenic or negative effects. This finding is disturbing, given that aggregating high-risk youth into treatment groups is a frequently employed therapeutic approach. Reviews of the literature also indicate that 29 percent of reported outcome analyses yield negative effects for youth with behavior problems (Lipsey 1992). Given that most evaluations of interventions with negative effects are unpublished, this is likely an underestimate of iatrogenic treatment effects, particularly for youth with CD.

Intervention Process

Clearly, professional skills are critical to the success of interventions, especially those that target parenting practices (Patterson 1985). Parents and other adults can develop negative attributions and expectations toward children with CD. Those issues must be sensitively addressed before interventions can move forward. Therapist skills in supporting and validating negative parenting experiences, while simultaneously encouraging proactive behavior management strategies, are especially important.

An exemplary parenting intervention designed to address conduct issues in young children utilizes videotaped modeling and collaborative group process to encourage change in parenting (Webster-Stratton 1990). For adolescents with more serious CD symptoms, Scott Henggeler and colleagues (1998) conducted parenting interventions in the home, expanding the array of issues addressed to include contextual, peer, and other systemic barriers to change. Thus, youth with extreme CD symptoms that warrant removal from the home may be effectively treated within a family-centered model.

Mark Eddy and Patti Chamberlain (2000) report that training foster parents in proactive behavior management skills and monitoring reduces serious delinquent behavior, compared to invoking group-home interventions. Though conduct problems may appear to be intractable, interventions that engage parents and buttress their efforts to improve family management skills can be effective in mitigating antisocial behavior.

Conclusion

Research regarding the origins of CD suggests that environmental and biological risk factors are primarily mediated through parenting and peer environments. Intervention research confirms the importance of promoting family management, attending to peer dynamics, and addressing self-regulation to reduce problem behavior in youth with CD.

Successful interventions are those that are flexible in delivery, promote a collaborative process with related individuals, and involve proactive behavior management. The prevalence of conduct disorder within a family can profoundly affect individual and collective functioning and initiate a cycle of frustration, negativity, and escalating behavior problems. It is important to engage families in processes that will mitigate the development of CD symptoms and promote positive and sustainable change in both parent and child behavior.

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bernadette marie bullock

thomas j. dishion

International Encyclopedia of Marriage and Family