Evidence based assessment/Conduct disorder (assessment portfolio)

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Demographic information[edit]

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of PBD that they are likely to see in their clinical practice.

Base rates of conduct disorder in different clinical settings and populations[edit]

Setting Base Rate Demography Diagnostic Method Best Recommend For
Nationally representative large-scale study (N=9282) - adult retrospective report[1] 9.5% overall: 12% males, 7% females All of U.S.A. CIDI: WHO Composite International Diagnostic Interview

(Parent Interview)

The Great Smoky Mountains Study – longitudinal, population-based study of community sample[2] 9.0% overall: 14% males, 4% females Western North Carolina CAPA: Child and Adolescent Psychiatric Interview

(Parent and Youth Interview)

Incarcerated adolescents[3] 93% males, 92% females California, Division of Juvenile Justice (DJJ) SCID-IV: Structured Clinical Interview for DSM-IV

(Youth Interview)

National Comorbidity Survey Replication Adolescent Supplement –population-based study of adolescents[4] 5.4% Overall All of USA CIDI

(Parent Interview)

Community samples – summary of past findings[5] 6-16% males, 2-9% females Various locations across USA Varied
Clinic-referred sample[6] 12.5% overall; 50% of those with CD met criteria for CU traits based on combined-informant report on APSD Urban Midwestern USA KSADS-PL
Community based sample[6] 16.2% overall; 32% of those with CD met criteria for CU traits based on combined-informant report on APSD Small metropolitan area in SE USA CSI-4, based on combined-informant report

Note: Despite a plethora of studies assessing prevalence of comorbidity of conduct disorder with other disorders (e.g., substance abuse, bipolar, ADHD), searches outlined below did not yield a single study providing a prevalence of conduct disorder alone in an outpatient or community clinic setting.

Diagnosis[edit]

ICD-10 Criteria[edit]

Conduct disorders are characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct. These behaviors violate age-appropriate social expectations, being more severe than ordinary childish mischief or adolescent rebelliousness in an enduring pattern of behavior (six months or longer). Features of conduct disorder can also be symptomatic of other psychiatric conditions, in which case the underlying diagnosis should be preferred.[7]

Examples of behavior on which the diagnosis of conduct disorder is based include excessive levels of fighting or bullying, cruelty to other people or animals, severe destructiveness to property, fire-setting, stealing, repeated lying, truancy from school and running away from home, unusually frequent and severe temper tantrums, and disobedience. Any one of these behaviors, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not.[7] The full list of these behaviors include that the individual:

1. has unusually frequent or severe temper tantrums for his or her developmental level;

2. often argues with adults;

3. often actively refuses adults' requests or defies rules;

4. often, apparently deliberately, does things that annoy other people;

5. often blames others for his or her own mistakes or misbehavior;

6. is often "touchy" or easily annoyed by others;

7. is often angry or resentful

8. is often spiteful or vindictive;

9. often lies or breaks promises to obtain goods or favors or to avoid obligations;

10. frequently initiates physical fights (this does not include fights with siblings);

11. has used a weapon that can cause serious physical harm to others (e.g. bat, brick, broken bottle, knife, gun);

12. often stays out after dark despite parental prohibition (beginning before 13 years of age);

13. exhibits physical cruelty to other people (e.g. ties up, cuts, or burns a victim);

14. exhibits physical cruelty to animals;

15. deliberately destroys the property of others (other than by fire-setting);

16. deliberately sets fires with a risk or intention of causing serious damage;

17. steals objects of non-trivial value without confronting the victim, either within the home or outside (e.g. shoplifting, burglary, forgery);

18. is frequently truant from school, beginning before 13 years of age;

19. has run away from parental or parental surrogate home at least twice or has run away once for more than a single night (this does not include leaving to avoid physical or sexual abuse);

20. commits a crime involving confrontation with the victim (including purse-snatching, exhortation, mugging);

21. forces another person into sexual activity;

22. frequently bullies others (e.g. deliberate infliction of pain or hurt, including persistent intimidation, tormenting, or molestation);

23. breaks into someone else's house, building, or a car.

It is recommended that the age of onset be specified:

  • childhood onset type: onset of at least one conduct problem before the age of 10 years;
  • adolescent onset type: no conduct problems before the age of 10 years.


Diagnostic strategy[edit]

The current strategy of diagnosis for Conduct Disorder is the Multistage Strategy for Evidence-Based Assessment of Conduct Disorder. [8] [9]

Stage 1:

The first stage of diagnosis uses any of the following evidence based assessments: Achenbach System of Empirically Based Assessments (ASEBA): Child Behavior Checklist (CBCL), Teacher Report Form (TRF), Youth Self-Report (YSR). These are used to broadly identify behaviors relevant to conduct disorder as outlined by the DSM. Both the Inventory of Callous Unemotional Traits and the Antisocial Process Screening Device (APSD) is assess whether child or adolescent is displaying callous and unemotional (CU) traits, a recently added symptom of conduct disorder as outlined by the DSM-5. There are multiple assessments taken by informants due to the covert nature of many conduct disorder problems.

Stage 2:

The second stage of diagnosis involves interviews with the patient. The Structured Diagnostic Interview (KSADS) is used to assess the potential comorbidity of conduct disorders. A semi-structured diagnostic interview (KSADS) is recommended due to its flexibility. The tool has been shown to gain client-specific information vital for case conceptualization and treatment planning, including clear descriptions of the child's behavior, peer relationships, and social skills. It also helps assess comorbidity. Age of onset of conduct problems is established in this phase, which helps determine developmental pathways.

Part of this stage of diagnosis also involves standardized intelligence tests and academic achievement screeners. Developmental and medical history is also obtained through clinical interviews. For children, clinicians may utilize observational analogues, including parent-child interactions through child's games, parent's games, and clean up. Parents will also submit a parent daily report for observation measures. Clinicians utilize this data to assess the level of functional impairment or adaptive disability according to scales such as the Child and Adolescent Functional Assessment Scale

Stage 3:

The third stage of diagnosis examines the patient's broader social and environmental context through Neighborhood Questionnaire, Community Interaction Checklist, and "Things I Have Seen and Heard" interviews. Assessment of social informational processing could yield important information relevant to the “three P’s”. Social information processing can be tested through an Intention-Cue Detection Task. It is also important to assess for familial risk factors through an antisocial behavior checklist. Further assessments specific to the symptomatology of the child or adolescent also should be conducted through assessments.

Covert conduct problem behaviors are difficult to assess, and the clinical utility of some innovative observational paradigms needs to be demonstrated. Research points to the “recent proliferation of research concerning girls and CP and suggest that this “should facilitate the development of evidence-based guidelines that are applicable to girls in the near future.” [8] For the time being, they recommend following the same guidelines for girls as for boys, with the addition of a measure of relational aggression in girls.


Screening instruments for conduct disorder[edit]

Rating scales for conduct problems[edit]

Measure Format (Reporter) Age Range Administration/

Completion Time

Inter-rater reliability Test-retest reliability Construct validity Content validity Highly recommended
ASEBA (Achenbach System of Empirically Based Assessment) not free <16 A E E G X
BASC-2 (Behavior Assessment System for Children, 2nd Edition) not free A E G E X
CASI-4 (Child Symptom Inventory for DSM-IV) not free A A G E
ECBI/ SESBI-R (Eyberg Child Behavior Inventory/Sutter-Eyberg Child Behavior Inventory-Revised) not free A A E E X

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Observational Coding Systems[edit]

Measure Format (Reporter) Age Range Administration/

Completion Time

Inter-rater reliability Test-retest reliability Construct validity Content validity Highly recommended
BCS (Behavioral Encoding System) A U G A X
DPICS (Dyadic Parent-Child Interaction Coding System) A L G A X
Compliance Test E A G A
ASEBA-DOF (ASEBA Direct Observation Form) not free G G E E

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Semi-structured and Structured Diagnostic Interviews[edit]

Measure Format (Reporter) Age Range Administration/

Completion Time

Inter-rater reliability Test-retest reliability Construct validity Content validity Highly recommended
DICA (Diagnostic Interview for Children and Adolescents) G G E E
DISC (Diagnostic Interview Schedule for Children) G G E E X

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Change in likelihood of conduct disorder based on rating scale scores[edit]

Screening Measure "(Primary Reference)" Area under curve (AUC) and Sample Size LR+ "(Score)" LR- "(Score)" Citation
Children and Adolescents (6-18 Years)
CBCL Rule-breaking T-Score
CBCL Aggression T-Score .80 (N=370) 4.18 (55+) .35 (<55) Hudziak, Copeland, Stanger, 2004[10]
Adolescents (12 to 18 years)
Antisocial Process Screening Device-Self-Report .72 (N=250) Pechorro, Maroco, Poiares, & Vieira, 2013
Antisocial Process Screening Device Self-Report** 1.56 (2+) 74 (<2) Kahn et al., 2012[6]
Inventory of Callous And Unemotional Traits .65 (N=341) 1.79 (26+) .61 (<26) Feilhauer, Cima, & Arntz, 2012

Note: “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes offormulation[11]; The Kahn et al., 2012 paper used 4 items from the APSD that mapped onto the DSM-V “Limited Prosocial Emotions” specifier.[12] Of these items , those that were scored as definitely true were rated as present and the presence of two of the four items met the specifier threshold

Searches (specified below) did not yield any data about sensitivity, specificity, AUC, or ROC for the Antisocial Process Screening Device, or for the Externalizing scale of the CBCL. Searches also did not yield data about TRF or YSR scales for Aggression or Externalizing: Achenbach and Rescorla (2001) provide data about clinically referred vs. non-referred samples but not about samples with conduct disorder specifically; thus, only AUC and LRs for the Aggression scale are reported. No studies were found that provide information about the likelihood of children or adolescents referred for conduct disorder receiving TRF or YSR Aggression or Externalizing scaled scores of a specific level versus non-CD youth receiving those scores.

Treatment[edit]

See Effective Child Therapy, a website sponsored by The Society for Child and Adolescent Psychology (APA, Division 53) and the Association for Behavioral and Cognitive Therapies (ABCT), for current summary of evidence-based treatments.

Process and outcome measures[edit]

Outcome and severity measures[edit]

Statistically significant change benchmarks with common instruments

Measure Subscale Cut-off scores* Critical Change
(unstandardized scores)
A B C 95% 90% SEdifference
Benchmarks Based on Published Norms
CBCL T-scores
(2001 Norms)
Externalizing 49 70 58 7 6 3.4
Conduct Disorder Samples Were Not Found in Searches*

Note: “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean

Search terms: (1)“antisocial process screening device,” (2) antisocial process screening device AND benchmarks, searches previously mentioned.

Process measures[edit]

See Table 1 in Section 1.1 for overview of evidence-based measures to use depending on etiology, symptomatology and conduct problems

External Resources[edit]

References[edit]

Click here for references
  1. Nock, M. K.; Kazdin, A. E.; Hiripi, E.; Kessler, R. C.. "Pravalence, subtypes and correlates of DSM-IV conduct disorder in the National Comorbidity Survey Replication". Psychological Medicine 36: 699-910.. 
  2. Costello, E. J.; Mustillo, S.; Erkanli, A.; Keeler, G.; Angold, A.. "Prevalence and development of psychiatric disorders in adolescence". Arch Gen Psychiatry 60: 837-844.. 
  3. Karnik, N. S.; Soller, M.; Redlick, A.; Silverman, M.; Kraemer, H.C.; Steiner, H.. "Psychiatric disorders among juvenile delinquents incarcerated for nine months". Psychiatric Services 60: 838-841.. 
  4. Kessler RC, Avenevoli S, Costello E, et al. Prevalence, Persistence, and Sociodemographic Correlates of DSM-IV Disorders in the National Comorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry. 2012;69(4):372-380. doi:10.1001/archgenpsychiatry.2011.160
  5. Farrington, D.P.. "Conduct disorder, aggression, and delinquency". Handbook of adolescent psychology: 324–345). Hoboken, NJ: Wiley.. 
  6. 6.0 6.1 6.2 Kahn RE, Frick PJ, Youngstrom E, Findling RL, Youngstrom JK. The effects of including a callous-unemotional specifier for the diagnosis of conduct disorder. J Child Psychol Psychiatry. 2012;53(3):271–282
  7. 7.0 7.1 "ICD-10 Version:2015". apps.who.int. Retrieved 2018-03-22.
  8. 8.0 8.1 McMahon, R.J.; Frick, P.J. (2005). "Evidence-based assessment of conduct problems in children and adolescents.". Journal of Clinical Child and Adolescent Psychology, 34: 477-50. 
  9. McMahon, R.J.; Frick, P.J. (2007). Conduct and oppositional disorders. In E.J. Mash & R.A. Barkley (Eds.), Assessment of childhood disorders (4 ed.). New York: The Guilford Press. pp. 132–183.
  10. Hudziak, J.J.; Copeland, W.; Stanger, C.. "Screening for DSM-IV externalizing disorders with the Child Behavior Checklist: a receiver-operator characteristic analysis.". Journal of Child Psychology and Psychiatry 45: 1299-1307. 
  11. Sackett, DL, Straus, SE, Richardson, WS, Rosenberg, W, Haynes, RB. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone, New York; 2000.
  12. Kahn, R. E., Frick, P. J., Youngstrom, E. , Findling, R. L. and Youngstrom, J. K. (2012), The effects of including a callous–unemotional specifier for the diagnosis of conduct disorder. Journal of Child Psychology and Psychiatry, 53: 271-282. doi:10.1111/j.1469-7610.2011.02463.x