Conduct Disorder

Conduct Disorder is a repetitive and persistent pattern of behavior that violates societal norms or the basic rights of others (American Psychiatric Association [ApA], 1994), covering four symptom areas: (1) aggressive behavior that threatens or causes physical harm to other people or animals (e.g., bullies, threatens, or intimidates others;), (2) nonaggressive conduct that causes property loss or damage (e.g., fire setting), (3) deceitfulness or theft (e.g., breaking into someone's house or car), and (4) serious violation of rules (e.g., truancy). To be diagnosed, at least 3 of 15 possible symptoms must have been displayed during the past 12 months. Childhood-onset Conduct Disorder is differentiated from adolescent-onset when at least one of the behavioral characteristics is evident before age 10.

Although some forms of aggressive behaviors are relatively common in mild forms during early childhood years, such behaviors become clinically significant if the instances are highly intense, high in frequency, or characterized by notably violent elements in later years. Estimated rates of Conduct Disorder are 6 to 16% for boys and 2 to 9% for girls (ApA, 1994), with boys outnumbering girls about three to one (Kazdin, 1998; Lochman & Szczepanski, 1999). Loeber (1990) hypothesized that aggressive behavior in elementary school years is part of a developmental trajectory that can lead to adolescent delinquency and Conduct Disorder. Similarly, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; ApA, 1994) indicates that Oppositional Defiant Disorder can evolve into childhood-onset Conduct Disorder and then into Antisocial Personality Disorder in adults. Longitudinal research has documented that aggressive behavior and rejection by chil dren's peers can be additive risk markers for subsequent maladjusted behavior in the middle school years (Coie, Lochman, Terry, & Hyman, 1992) and for substance use, overt delinquency, and police arrests in later adolescent years (Coie, Terry, Zakriski, & Lochman, 1995; Lochman & Way-land, 1994). Children are more at risk for continued aggressive and antisocial behavior if they display aggressive behavior in multiple settings and if they develop so-called versatile forms of antisocial behavior, including both overt and covert behaviors by early to mid-adolescence (Lochman & Szszepanski, 1999).

The developmental trajectory leading to childhood-onset Conduct Disorder may start very early among inflexible infants with irritable temperaments (Loeber, 1990). These children are at risk for failing to develop positive attachments with caregivers, displaying high rates of hyperactivity and inattention in the preschool years, and becoming involved in increasingly coercive interchanges with parents and significant adults, such as teachers. Moffitt (1993) has suggested that life-course-persistent delinquents ("early starters") are at risk because of combined biological and family factors. In some children, family dysfunction may be sufficient to initiate this sequence of escalating aggressive behavior. Parents of aggressive, conduct problem children often display high rates of harsh, inconsistent discipline, have unclear rules and expectations, and have low rates of positive involvement, adaptive discipline strategies, and problemsolving skills (Lochman & Wells, 1996; Patterson, 1986).

Loeber (1990) hypothesized that children begin to generalize their use of coercive behaviors to other social interactions, leading to increasingly aggressive behavior with peers and adults and to dysfunctional social-cognitive processes, which in turn serve to maintain problem behavior sequences. For example, aggressive children tend to have hostile attributional biases and problem-solving strategies that rely on forceful, direct action rather than verbal, negotiation strategies, and they expect that aggressive solutions will work (Crick & Dodge, 1994). These information-processing difficulties are made worse for aggressive children because of their dominance-oriented social goals, pervasive schema-based expectations for others' behavior, and strong physiological reactivity in response to provocation (Dodge, Lochman, Harnish, Bates, & Pettit, 1997; Lochman & Dodge, 1998; Lochman & Szczepanski, 1999), as well as their poor verbal fluency and abstract reasoning abilities (Kazdin, 1998). Furthermore, children displaying aggressive behavior are often socially rejected by their peer group and can become more withdrawn and isolated. By early to middle adolescence, they are prone to meeting their affiliation needs by gravitating toward deviant peer groups, which can become an additional proximal cause for delinquent behavior (Coie et al., 1995; Patterson, Reid, & Dish-ion, 1992).

Historically, psychosocial treatment of antisocial, conduct-disordered youths has been perceived to be difficult and not very productive. However, in recent years random ized clinical research trials have identified empirically supported treatments for Oppositional Defiant Disorder and Conduct Disorder. Brestan and Eyberg (1998) have identified two parent-training intervention programs with well-established positive effects (Patterson et al., 1992; Webster-Stratton, 1994) and ten other programs as probably efficacious for treating Conduct Disorder. Kazdin (1998; Kazdin & Weisz, 1998) has similarly identified several positive treatment approaches for Conduct Disorder, including Parent Management Training, Functional Family Therapy, Cognitive Problem-Solving Skills Training, and Multisys-temic Therapy. Parent Management Training and Functional Family Therapy are directed at dysfunctional parenting processes and have produced significant improvements in parenting practices and reductions in children's aggressive conduct problem behavior (Alexander & Parsons, 1973; Eyberg, Boggs, & Algina, 1995; Peed, Roberts, & Forehand, 1977; Webster-Stratton, 1994; Wiltz & Patterson, 1974). Cognitive-behavioral treatments designed to assist children's anger management, perspective-taking, and problem-solving skills have produced improvements in children's abilities to accurately perceive others'intentions and to generate more competent problem solutions and have led to reductions in problem behaviors (Feindler, Marriott, & Iwata, 1984; Kazdin, Siegel, & Bass, 1992; Lochman, Burch, Curry, & Lampron, 1984). Multisystemic treatment relies on individualized assessments of antisocial youths and the impaired systems around them (e.g., parents, peer groups, school bonding) and uses intense, individualized treatment plans to affect these systems, producing significant reductions in antisocial behavior among seriously delinquent youth (Henggeler, Melton, & Smith, 1992). In recent years, there has been a focus on developing and evaluating effective multicomponent interventions that target both the social-cognitive and parenting skill deficits evident in Conduct-Disordered youths and their families (Kazdin et al., 1992; Webster-Stratton & Hammond, 1997). Intensive, comprehensive prevention programs have also been developed and evaluated with high-risk children starting as early as first grade, and the results indicate that aggressive behavior and Conduct Disorder can be reduced through early intervention (Conduct Problems Prevention Research Group, 1999; Vitaro, Brendgen, Pagani, Tremblay, & McDuff, 1999).

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