Conduct Problems in Children and Adolescents

What is one of the most common reasons for child mental health referrals?

Conduct problems

What are frequent comorbidities of conduct problems?

ADHD, learning difficulties, anxiety, and depression

What are associated outcomes of conduct problems? (Name 3/6)

Educational disengagement and school exclusion

Substance misuse

Juvenile and adult offending

Relationship difficulties

Unemployment

Ongoing mental health difficulties

How does conduct disorder relate to Antisocial Personality Disorder?

Conduct disorder before age 15 is a diagnostic criterion for ASPD, however, many children with Conduct Disorder do not go on to develop ASPD

Evidence suggests what differences in conduct problems in different racial and ethnic populations?

Prevalence estimates, referral patterns, school discipline, and youth justice involvement

What are social determinants which influence racial and ethnic differences in conduct problems?

Poverty and inequality

Exposure to adversity

Educational opportunity

Structural disadvantage

Access to services

Due to disparities in youth justice involvement for Maori rangatahi, assessment needs to consider what?

Historical context, cultural identitiy, and whanau strengths and structural influences

How do conduct problems relate to clinician biases? What may clinical judgements be influenced by?

Conduct problems are among the most socially and culturally influenced dxs in child mental field

May be influenced by child factors (gender, ethnic biases, socioeconomic assumptions, presentation), professional factors (confirmation bias, attribution biases, risk-focused thinking, dx overshadowing), and system factors (school disciplinary practices, referral pathways, youth justice involvement, cultural mismatch between clinician and family).

What are conduct problems? What are types of conduct problems?

A broad range of age-inappropriate behaviours that violate social norms, family expectations, or the rights of others.

Oppositional, aggressive, and antisocial behaviours

WHat are oppositional behaviours?

Arguing with adults, refusing requests, deliberately annoying others

What are aggressive behaviours?

Hitting, fighting, bullying, threatening

What are antisocial behaviours?

Theft, property destruction, vandalism, truancy

What are dimensions of conduct problems, according to Frick?

Range from Destructive to Non-Destructive, Covert to Overt

A: Property violations fall where on Frick’s multidimensional model? What are examples of these?

Destructive and covert.

Involves cruelty to animals, stealing, vandalism, fire setting, and lies

B: Aggression to People falls where on Frick’s multidimensional model? What are examples of this?

Destructive and overt

Assault, blames others, fights, bullies, spiteful

C: Status violation falls where on Frick’s multidimensional model of conduct problems? What are examples of this?

Covert and non-destructive

Runaway, truancy, substance abuse, breaks rules, swears

D : Oppositional falls where on Frick’s Multidimensional model of conduct problems? What are examples of this?

Overt and non-destructive

Annoys, defies, argues, angry, stubborn, touchy, temper

How does aggression relate to a developmental perspective? What are children born not knowing how to do? When would conduct problems become clinically concerning?

Aggression is a developmental phenomenon.

Children are not born knowing how to regulate emotions, negotiate conflicts, tolerate frustration, or delay gratification.

They are clinically concerning when persistent, pervasive, developmentally inappropriate, and/or associated with significant impairment

How does aggression change throughout typical development?

Anger - emerges in infancy

Physical aggression - peaks during toddlerhood

Verbal and social problem solving skills increase across childhood, and aggression generally declines for most children

Why do some highly aggressive toddlers become well-adjusted adolescents while others develop persistent conduct problems?

Equifinality - different pathways, same outcome

• ADHD/trauma/harsh parenting/language difficulties → conduct problems

• There will be different formulations and interventions

Multifinality - same risk factor has different outcomes

• Harsh parenting → Conduct problems/anxiety/depression/no disorder

Outcomes influenced by child factors, protective factors, timing, and context

What is the core feature of DSM-5-TR Disruptive, Impulse Control, and Conduct Disorders?

Difficulties with impulse control, self-regulation, and aggression

What is the behavioural pattern of DSM-5-TR Disruptive, Impulse Control, and Conduct Disorders?

Actions typically harm others’ safety and/or violate social norms

For example, fighting, property destruction, defiance, stealing and lying, and rule-breaking

What is the developmental course and gender prevalence of DSM-5-TR Disruptive, Impulse Control, and Conduct Disorders?

Usually emerge in childhood and may persist into adulthood.

Prevalence is more common in males except for kleptomania

What are the DSM-5-TR Disruptive, Impulse Control, and Conduct Disorders? (7 total, name the big 2)

Oppositional defiant disorder (ODD)

Intermittent explosive disorder

Conduct disorder (CD)

Pyromania

Kleptomania

Other specified

Unspecified

Oppositiional defiant disorder is a ____, where emotional dysregulation is expressed as ______.

‘hot’ emotional dysregulation disorder; angry or irritable mood, argumentative, or defiant behaviour or vindictiveness

Opposition defiant disorder is defined as what?

Age-inappropriate recurrent pattern of stubborn, hostile, disobedient, and defiant behaviours

ODD usually appears by age ____, and has a prevalence rate of __%.

8; 3.6

THose with ODD are at an increased risk for _____ due to ____.

Internalising problems; angry-irritable

ODD symptoms are related to a pattern of ________, usually ______. This can have ________.

problematic interactions with others; parents or caregivers. negative effects on parent-child interactions

Unliked ODD which is a _____ disorder, Conduct disorder is a ______ disorder, meaning it may be less _______ and more ______.

“hot”; “cool”; less emotionally driven and may be more deliberate or goal-directed

Conduct disorder is defined as what?

Repetitive, persistent pattern of severe aggressive and antisocial acts

What are co-occurring problems for Conduct Disorder?

ADHD, academic deficiencies, and poor peer relations

When does conduct disorder tend to emerge? What is its prevalence?

During childhood-middle adolescence; 2.1%

What usually contributes to problems from Conduct Disorder?

Family child-rearing practices—parents feel the children are out of control and feel helpless to do anything about it

How does childhood onset of CD differ from adolescent onset?

Childhood onset:

• more likely to be boys

• Show more aggressive symptoms

• Account for disproportionate amount of illegal activity

• Poorer prognosis, higher rates of psychopathology across childhood, adolescence, and adulthood

Adolescent onset:

• As likely to be girls as boys

• Does not show the severity of psychopathology characterising early onset group

• Less likely to commit violent offenses or persist in antisocial behaviour over time

What are Moffitt’s 2 courses of CD?

Life-course persistent - early onset, neurodevelopmental vulnerabilities, family adversity, higher longer term risk

Adolescent-limited - later onset, peer influenced, often improves during adulthood

Are CD and ODD separate?

While ODD is often a precursor to development of CD, and earlier onset of ODD is a risk of progression to CD, many children and adolescents with ODD do not develop CD.

For most children/adolescents, ODD is an extreme developmental variation that does not usually escalate to more severe conduct problems.

They are also at increased risk for a number of adulthood problems including persistence of ODD, impulse control difficulties, substance misuse, anxiety, and depression

How do ODD and CD differ in behaviour, physical condition, and interpersonal adjustment?

ODD behaviour focuses on defiance towards adults in authority (aggression, temper tantrums, vindictiveness), CD is persistent antisocial behaviour (aggression, destructiveness, deceitfulness, cruelty, truancy, drug use).

ODD lacks a physical condition, while CD has physical probelms associated with risk-taking including fighting, drug abuse, casual unsafe sex, and reckless driving

ODD has problematic relationships mainly with parents, CD has problematic relationships with parents, teachers, peers, and police

What are callous-unemotional traits?

A (temperamental) pattern characterised by:

• limited empathy

• Lack of guilt or remorse

• Reduced concern about performance

• SHallow or restricted emotional expression

• Reduced responsiveness to other’s distress

Children with elevated C-U traits do what?

Display more severe conduct problems

Show earlier onset difficulties

Are more likely to engage in proactive aggression

Have poorer long-term outcomes

Often respond less well to traditional interventions

What are emotional characteristics of children with C-U traits?

Reduced empathy,

limited guilt,

reduced fearfulness,

shallow affect

What are cognitive characteristics of children with C-U traits?

Less sensitive to punishment,

underestimate likelihood of consequences,

more accepting of aggression,

view manipulation as acceptable

What are interpersonal characteristics of children with C-U traits?

Controlling relationships,

reduced emotional reciprocity,

difficulties maintaining friendships

How is irritability important to ODD/CD?

The focus on behaviour means we miss the irritability component.

Parent emotion dysregulation increases risk for child conduct problems

Irritable children show heightened physiological reactivity to stress and threat.

Irritability is linked to reactive (emotion-driven) aggression

Persistent irritability predicts later depression, suicidality, and anger, especially with low parental warmth.

What are historical theories for the developmental of Conduct problems?

Behavioural learning

Social learning

Family interaction patterns

Cognitive processing biases

Contemporary understandings of conduct problems etiology propose that conduct problems emerge through…

interactions between child characteristics, family relationships, school experiences, peer influences, and wider social contexts

Behavioural theories of conduct problems assume that _____, and that aggressive behaviour may be reinforced by _______. Therefore, to understand behaviour, we must do what?

Behaviour is shaped and maintained by consequences';

attention, escape from demands, access to desired objects, control over situations;

Understand what purpose is serves

What is Patterson’s Coercion Theory?

Conduct problems develop through escalating interaction cycles.

Parent demand → Child noncompliance → parent escalation → child escalation → parent withdraws → immediate relief → cycle reinforces

Parents not intentionally causing problems—cycles occur in attempts to reduce distress

Parental withdrawal key part → increases the likelihood through inadvertent reinforcement

What is Dodge, Crick, & Dodge’s Social Information Processing theory?

Essentially, children are not responding directly to the situation but their interpretation of the situation

Encoding cues → mental representation and interpretation → response generation → evaluation → enactment of responses

• Increased attention to hostile cues, primed by previous knowledge

• Mental representations and interpretations have more hostile attribution bias, cognitive errors, and ATs.

• Response generation is from memory and fewer

• Evaluation of consequences, morality, and acceptability are more favourable toward aggression

Problems at any stage can result in angry or aggressive responding

What does Carr’s Developmental Systems Framework do?

Incorporate context into previous theories to reflect interactive systems, not separate risk factors

Includes macro (culture, norms), exo (SES, neighborhood, parental stress), micro (family, parenting factors), and individual factors which interact to increase conduct problems

What are child factors for risk of conduct problems?

Temperament

Emotion regulation and irritability

Executive functioning, ADHD, and neurodevelopment

What are temperament risk factors for Conduct Problems?

High emotional reactivity

Impulsivity

Low frustration tolerance

Fearlessness

Activity level

Irritability is a tendency towards __, _, and _, associated with ____, ____, ____, and ____.

Frequent anger; easy frustration; emotional over-reactivity

Reactive aggression; family conflict; depression risk; later emotional difficulties

Many behaviours interpreted as oppositional may actually partly reflect differences in what?

Executive functioning

Children with ADHD may show what that leads to behaviours perceived as oppositional?

Impulsive aggression

Frustration intolerance

Difficulties learning from consequences

Attachment difficulties associated with conduct problems development may include?

Inconsistent responsiveness

Emotional unavailability

Hostile interactions

Relationship disruption

What parenting factors influence conduct problems?

Inconsistent discipline

Harsh discipline

Low warmth

Limited monitoring

Escalating conflict

Parental criminality

Bidirectional relationship between parents behaviour and children

How does trauma relate to conduct problems?

Trauma can have effects such as:

• Hypervigilance

• Threat sensitivity

• Emotion dysregulation

• Aggression as a coping mechanism

• Relationship dififculties

Trauma should always be assessed

School experiences can act as _______, _____, and ______ factors.

risk factors, protective factors, and maintenance

How do protective relationships influence conduct problems?

Even one supportive adult can significantly alter developmental trajectories

What is the peer rejection and developmental cascade?

Aggressive behaviour → peer rejection → reduced opportunities to learn social skills → loneliness and anger → further aggression → more rejection

Vicious cycle

Deviant peer affiliation due to rejection, which may reinforce conduct problems