Research roundup: Conduct disorder

This issue reviews the recent addition of a specifier to the diagnosis of conduct disorder (CD) in the DSM-5, as well as a sampling of research related to the disorder and possible implications for treatment.

By Practice Research & Policy staff

Conduct disorder (CD) as defined by the DSM-5 is characterized by behavior that violates either the rights of others or major societal norms. The diagnosis of conduct disorder now includes a specifier of callous-unemotional (CU) traits. After reading these summaries, those practitioners interested in methods for treating CD may want to delve more completely into the literature to determine what may be useful in their practices.

Barry, C. T., Frick, P. J., Golmaryami, F. N., & Rivera-Hudson, N. (2013). Evidence-based assessment of Conduct Disorder: Current considerations and preparation for DSM-5. Professional Psychology: Research and Practice, 44(1) 56-63. Doi: 10.1037/a0029202

Summary

Currently, there is no definitive model of specific measures to accurately assess and guide treatment for Conduct Disorder (CD). The authors summarize evidence on the etiology, progression and phenomenology of CD, while considering the criteria found in the DSM-5 (American Psychiatric Association) including the three specifiers of the disorder. The DSM IV divided CD diagnosis into childhood-onset and adolescent-onset whereas DSM-5 also includes the option of specifying a callous and unemotional presentation. In order to use that specifier, a youth must meet criteria for CD and present with two or more callous-unemotional (CU) traits (lack of remorse or guilt, lack of empathy, lack of concern over performance in important activities and/or shallow affect). 

According to recent studies, a small percentage of youths with CD also exhibit traits akin to adult psychopathy. Because treating children and adolescents with significant CU traits is more challenging than if elevated CU traits are not a factor, their presence has vital implications for treatment. Studies suggest that CD that begins in childhood results in a poorer prognosis and increased risk of developing antisocial behaviors in adulthood. Thus, age of onset is a critical factor in CD assessment and treatment planning.  

The authors present four major practical implications from CD research. First, since conduct problems vary greatly in type and severity, assessment tools must cover a wide range of behaviors and provide a way to measure levels of severity. Second, since patients with CD also present with multiple comorbidities, assessments must also screen for a range of disorders. Third, risk and protective factors, which may play a role in the development and course of CD, must be assessed. Finally, assessments for CD should identify key constructs that could discern different developmental pathways to CD that will affect treatment.

The authors analyzed the usefulness of various assessment tools in diagnosing and treating CD. Broad-band behavior rating scales are helpful in providing norm-referenced assessment of CD behaviors and identifying potential areas of comorbidity. However, it’s essential that multiple informants complete these rating scales in order to get an accurate picture of the patient’s behavior.

Another important assessment tool is behavioral observations conducted in the classroom, the home and/or in settings developed by the clinician.

With the addition of CU traits in the DSM-5 criteria for CD, a narrow-band measure of CU traits is also recommended. For example, the Inventory of Callous Unemotional Traits (ICU; Frick, 2004) has good internal consistency and seems to be a useful tool.     

Practical Implications

Psychologists may want to consider using multiple informants and sources to document that a youth meets diagnostic criteria for a CD diagnosis. Specific information about the patient’s behavioral problems, age of onset and presence of diagnostic symptoms could be gained through interviews with parents and/or teachers. In addition to interviews, norm-referenced information can be obtained through broad-band behavioral rating scales and narrow-band measures of CU traits. It may be advisable after initial diagnosis to monitor the patient’s progress carefully to identify other targets of intervention.

Frick, P. J., Ray, J. V., Thornton, L. C., & Kahn, R. E. (2014). Can callous-unemotional traits enhance the understanding, diagnosis, and treatment of serious conduct problems in children and adolescents? A comprehensive review. Psychological Bulletin, 140(1) 1-57.

Summary

This comprehensive review of studies of CU or psychopathic traits in youth examined research published since 1990. Three major issues are described. 

First, research suggests children and adolescents with severe conduct problems coupled with high CU traits have a less than average response to punishment and fear or anguish in other people. Compared to other antisocial children and adolescents, they present with lower levels of anxiousness and have increased tendencies toward risk-taking behaviors. Youths with CU traits appear to more frequently have experienced forceful and antagonistic parenting than youths without CU traits. 

Second, the connection between aggressive behaviors, delinquency and antisocial behavior and CU traits were examined in 118 studies. Of those studies, 105 (89 percent), provided evidence that CU traits are linked to aggressive and antisocial behaviors. 

Finally, the review looked at studies that examined treatment outcomes in children and adolescents with elevated CU traits. Twenty studies compared youths with CU traits and without CU traits. In 18 of those studies (90 percent) the patients presenting with higher CU traits showed poorer prognosis. Studies noted that the poorer outcomes were often because the quality of a patient’s participation was poorer or the patient refused to participate in treatment at all. Despite this, when treatments were designed in a way to address an individual’s unique needs, taking into account their emotional and motivational style, a patient with high CU traits could be treated effectively.

Practical Implications

This review underscores the need to understand the extent of CU traits in those with CD in order to deliver the most appropriate care. Given the generally poorer outcomes for those with CD and the even worse prognosis for those with CD and CU traits, psychologists will want to carefully assess for the presence of such traits and design treatment plans accordingly. Improved strategies to engage and keep individuals in treatment are needed. Treatment research could be guided by a focus on the specific cognitive, emotional, biological, personality and environmental correlates to CU traits.

August, G. J., Bloomquist, M. L., Hektner, J. M., Klimes-Dougan, B., & Lee, S. (2013). A 10-year randomized controlled trial of the Early Risers Conduct Problems Preventive Intervention: Effects on externalizing and internalizing in late high school. Journal of Consulting and Clinical Psychology, 1-6. Doi: 10.1037/a0035678 

Summary

This study examined the Early Risers “Skills for Success” Conduct Problems Prevention Program (ER), a multi-dimensional program designed to disrupt the beginnings of social, emotional and behavioral conduct problems in youths by building up emotional and behavioral regulation and social skills, and supporting adjustment to school.

Two hundred and forty-five kindergarteners (mean age = 6.6 years, 68.6 percent male) evaluated by teachers exhibiting aggressive behavior were randomly assigned to participate in either ER for three years with two booster years, or serve as controls. After a baseline assessment was administered, youths in the ER program participated in 144 hours of structured activities in the summer over six weeks, followed by two summers in which a six-day booster camp was made available. 

Data from parents and teachers measuring potential mediators was gathered at baseline, in third grade and in the last year of the program. Data on gender, externalizing problems and internalizing problems was also recorded. In the first two years of ER, youths showed academic improvement and better behavior in school than the control participants. By the third year of the ER program, the most aggressive youths had not only demonstrated improved self-regulation and social skills, but had maintained these gains.

One hundred and twenty-nine of the original participants were given the National Institute of Mental Health Diagnostic Interview Schedule for Children Version IV in high school (mean age = 16.3). Youths in the ER program showed greater decreases in CD, oppositional defiant disorder (ODD), and major depressive disorder (MDD) than the controls did. The program participants had approximately 1.81 fewer symptoms of CD than their control group peers, with a 95 percent confidence interval. With the ER program, it appears that improved social skills learned by the third grade then resulted in decreased CD symptoms by high school.

Practical Implications

Children who demonstrate disruptive behavior can benefit from intensive early intervention with long term positive results; yet for many providers and families such care is not feasible or accessible. Psychologists may want to consider how such programs could be implemented in local communities and what data is necessary to gather in order to demonstrate the program’s value. 

Caron, A., Catron, T., Gallop, R., Han, S., Harris, V., Ngo, V. K., & Weiss, B. (2013). An independent randomized clinical trial of multisystemic therapy with non-court referred adolescents with serious conduct problems. Journal of Consulting and Clinical Psychology, 81(6) 1027-1039. Doi: 10.1037/a0033928

Summary

Multisystemic Therapy (MST) is one of the most frequently used methods for treating conduct problems in adolescents. However, most evaluations of MST have been done by the program developers. The authors of this study conducted an independent review of MST with non-court referred adolescents with conduct problems.

Participants included 164 adolescents between the ages of 11 and 18 selected from behavior intervention classrooms in public schools. They, along with their families, were randomly assigned to receive MST or treatment as usual and were monitored for 18 months after baseline by utilizing parent, adolescent and teacher reports. Conduct problems, functioning in school and court records of criminal behavior were all used as outcome measures.

The Child Behavior Checklist (CBCL) was completed by parents, adolescents and teachers to assess the primary outcome of conduct problems. Both parents and adolescents participating in MST reported significantly greater decreases in externalizing problems than those receiving treatment as usual. Teachers, however, did not report significant treatment effects.

Antisocial behaviors, drug use and school functioning were assessed as secondary outcomes using the Self-Report Delinquency Scale (SRD). While MST had no significant effect on patients’ reports of antisocial behavior or drug use, MST did have a significant effect on certain aspects of school functioning, such as school absences. MST parents reported a greater decrease in permissive parenting as well as diminished internalizing psychopathology than control parents did.

The Parental Authority Questionnaire (PAQ) was distributed to primary care givers to evaluate parenting behavior. The Personality Assessment Inventory (PAI) and Cohesion Evaluation Scales-III (FACES-III) were given to parents to assess family relationships. These measures all showed positive effects as the result of MST.

Practical Implications

This study reinforces the efficacy of MST for the treatment of conduct disorder in children and adolescents. Treatment fidelity can be realized as long as satisfactory resources to ensure the continuation of MST are available. Additionally, most clinicians seem to approve of MST’s precepts as reasonable.