Conduct Disorder and Offending Behaviour in Young People

Findings from Research

Joanna Richardson, Kristin Liabo

• Publisher: Jessica Kingsley Publishers
• Year: 2007
• Print ISBN: 9781843105084
• eBook ISBN: 9781846426605
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

`This is the latest in a series of accessible, evidence-based resources from Jessica Kingsley Publishers for those seeking to understand and promote young people's mental health. Trawling through the evidence, the authors start by looking at the nature and prevalence of conduct disorders including attention-deficit hyperactivity disorder and how they relate to factors such as depression, substance misuse and learning disabilities. They also look at preventive methods and services available to adolescents in the wake of Ever Child Matters. The book then deals with different approaches to treatment, from individual programmes using cognitive behaviour therapy to family, school-based and pharmacological interventions. It suggests family therapies are the most promising, with little evidence supporting the efficacy of medication.'

- Youth Work Now

Offending behaviour in young people is a problem not only for affected neighbours and communities; it is also a serious problem for the young people involved. Behaviour problems and involvement in criminal activities have been linked to continued offending, substance misuse, lack of education and work - all factors that are linked, in turn, with shorter life expectancy.

This book reviews the literature on a number of techniques and treatment approaches designed for use with adolescent conduct disorder and young offenders. The authors also provide an overview of the condition including its developmental pathway; the criteria for diagnosing conduct disorder, and services for adolescents.

Conduct disorder and offending behaviour in young people are complex problems that need multi-agency, multifaceted solutions. This book aims to contribute to the design of services by drawing on a wide range of high-quality research, and presents it for the non-specialist. It is essential reading for child and adolescent mental health practitioners, social workers, youth offending teams and other professionals working with young people with conduct problems and their families.

Part One

Introduction

1Overview of Conduct Disorder

Definitions and terminology

Conduct disorders are characterised by a repetitive and persistent pattern of antisocial, aggressive or defiant behaviour. Young people with conduct disorder may exhibit excessive levels of fighting or bullying; cruelty to animals or other people; severe destructiveness to property; firesetting; stealing; repeated lying; truancy from school and running away from home; unusually frequent and severe temper tantrums; and defiant provocative behaviour. The behaviours that are associated with conduct disorder are major violations of age-appropriate social expectations, and are more severe than ordinary childish mischief or adolescent rebelliousness (BMA Board of Science 2006). Isolated antisocial or criminal acts are not in themselves grounds for the diagnosis of conduct disorder, which requires an enduring pattern of a range of difficult behaviour of at least six months prior to diagnosis (see Appendix 1 for ICD-10 (WHO 1994) and DSM-IV (APA 1994) diagnostic criteria).

The diagnostic criteria for conduct disorder are similar but not identical to antisocial personality disorder. According to the International Classification of Diseases (ICD-10) (WHO 1994) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (APA 1994), conduct disorder usually occurs during childhood or adolescence, whereas antisocial personality disorder is not diagnosed in people under the age of 18. Furthermore, according to ICD-10 and DSM-IV criteria, any diagnosis should distinguish between early-onset (symptoms present before the age of ten) and late-onset conduct disorder (absence of symptoms before the age of ten). The diagnostic criteria are also similar to oppositional defiant disorder (ODD), which according to ICD-10 usually occurs in younger children and ‘does not include delinquent acts or the more extreme forms of aggressive or dissocial behaviour’ (WHO 1994). ODD is generally seen as milder than, and a risk factor to developing, conduct disorder.

Several terms have been used to describe conduct disorder, including antisocial behaviour, acting out, externalising behaviour, disruptive behaviour and conduct problems (Kazdin 1995). The diagnostic criteria described above have been criticised for ignoring the context in which antisocial behaviour and conduct problems occur. Considering the strong correlation between conduct disorder and social deprivation, this criticism is in many ways well-founded. The aetiology of conduct disorder is complex, and it can be argued that ICD-10 and DSM-IV fail to account for these complexities, including comorbidity. However, for research purposes, the diagnostic criteria are useful as a common language (Richters and Cicchetti 1993).

Offending behaviour often presents itself during the adolescent years. This may amount to no more than one or two incidents of shoplifting or graffiti, or it may escalate into persistent, and sometimes more serious, criminal behaviour. The Home Office has defined persistent young offenders as a person who is ‘aged 10–17 who has been sentenced for one or more recordable offences on three or more separate occasions and is arrested again (or has an information laid against him or her) within three years of last being sentenced’ (Home Office 1997).

Juvenile delinquency is a social, rather than a diagnostic, category that refers to children and adolescents who break the law. Delinquent behaviour may well lead to or be part of a diagnosis of conduct disorder, but not all children or adolescents who offend are conduct disordered. More research is needed on the link between youth crime and health. Services aimed at young offenders have tended to remain distinct from those provided by the health sector. Research looking at the prevalence of mental health problems in young offenders has reported high rates (Department of Health 2004; Hagell 2002). One UK study estimated that over 50 per cent of remanded young males and over 30 per cent of sentenced young males have a diagnosable disorder (Liddle 1999). Conduct and oppositional disorders are the most frequent diagnoses, and these often occur alongside attention-deficit disorders or depression (Hagell 2002). There are a number of behaviours that overlap with the formal conduct disorder diagnosis but the differences between those who are incarcerated and those who obtain treatment in mental health settings for conduct disorder may be small (Hagell 2002; Shamsie, Hamilton and Sykes 1996).

Prevalence

In the latter part of the last century there was a sharp increase in rates of antisocial disorder, suicidal behaviour, depressive disorder and substance abuse among young people (Rutter 1999). Conduct disorders are now the most prevalent mental health problem in young people. In a British survey of young people between the ages of 11 and 15 it was found that, overall, conduct disorders occur in 7 per cent of the population (up from 6.2% in 1999), affecting 8.1 per cent of males (8.6% in 1999) and 5.1 per cent of females (3.8% in 1999) (Green et al. 2005). Table 1.1 provides a breakdown of these prevalence figures by types of conduct disorder.

Table 1.1 Prevalence rates of conduct disorder in Great Britain for young people aged 11–15
Type of conduct disorder	Boys (%)	Girls (%)	All (%)
Oppositional defiant disorder	3.5	1.7	5.2
Unsocialised conduct disorder	1.2	0.8	2.0
Socialised conduct disorder	2.6	1.9	4.5
Other conduct disorder	0.7	0.8	1.5
Source: Green et al. 2005. Crown copyright 2005)

In general, children with conduct disorder were more likely to be living in social sector housing, with neither parent working, and where the interviewed parent had no educational qualifications. They were less likely to be living with married parents, and more likely to be living in a household with stepchildren (Green et al. 2005). Of all young people who present to child and adolescent mental health services (CAMHS) for treatment, it is estimated that between 40 per cent and 60 per cent had some form of disruptive, antisocial or aggressive behaviour (Audit Commission 1999).

Conduct disorder is particularly prevalent among young people in local authority care, and surveys have found clinical conduct disorder rates in this population to be 37 per cent in England, 36 per cent in Scotland, and 42 per cent in Wales (Meltzer et al. 2002, 2004a, 2004b). Conduct disorders appear to be more prevalent in young people placed in residential care (Meltzer et al. 2002).

Long-term outlook

There has been a growing awareness of the social and financial costs associated with a conduct disorder diagnosis (House of Commons Health Committee 1997; Scott et al. 2001). Main costs are associated with crime: one study found that two thirds of the total cost of conduct disorder was related to crime. Large costs were also associated with disruptive education, being in care, and receiving benefits (Scott et al. 2001).

It has been noted that it is rare to find an antisocial adult who did not exhibit conduct problems as a child (Robins 1966, 1978), and approximately 40–50 per cent of children with conduct disorder go on to develop antisocial personality disorder as adults (American Academy of Child and Adolescent Psychiatry 1997; Loeber 1982; Rutter and Giller 1983). The Cambridge study in delinquent development found that early starting patterns of conduct disorder were remarkably stable, with half of the most antisocial boys at ages 8 to 10 still being antisocial at age 14 and 43 per cent remaining among the most antisocial at age 18 (Farrington 1989; Farrington, Loeber and Van Kammen 1990).

Other psychiatric disturbances associated with childhood conduct disorder are substance abuse, mania, schizophrenia and obsessive compulsive disorder, major depressive disorders and panic disorder (Maughan and Rutter 1998; Robins 1966). Adult antisocial behaviours associated with childhood conduct disorder include theft, violence towards people and property, drink driving, use of illegal drugs, carrying and using weapons, and group violence (Farrington 1995). Conduct disorder in childhood has also been linked to incomplete schooling, joblessness and consequent financial dependency, poor interpersonal relationships and abuse of the next generation of children (Robins 1991; Rutter and Giller 1983). Problem behaviour that starts in adolescence affects about one quarter of the general population, and generally does not persist into adulthood (Moffitt 2003).

2Young People With More Than One Disorder (Comorbidity)

Conduct disorder is itself a complex disorder, which is further complicated by the fact that young people with behaviour disorders often have other conditions (Greene et al. 2002; Maughan et al. 2004). Comorbidity can be defined as the ‘simultaneous occurrence of two or more unrelated conditions’ (Caron and Rutter 1991, p.1063). Disorders that are likely to occur with conduct disorder are: attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and depression (Greene et al. 2002; Rey 1994). Comorbidity can have important implications for the development, diagnosis and treatment of conduct disorder (Stahl and Clarizio 1999):

•Comorbidity in teenagers is more common than a single disorder. For this reason it is vital that a comprehensive initial assessment is carried out.

•Issues arise as to the need for a combined category for disorders that commonly occur together. This has been the case for the ICD-10 category of hyperkinetic conduct disorder, which refers to a comorbid conduct disorder and hyperactivity disorder.

•When a disorder typically precedes another such as in the relationship with oppositional defiant and conduct disorder, it has been suggested that the first disorder could be a vulnerability factor for the second. A series of studies on clinic samples showed that among those with conduct disorder, the risk for affective disorder is increased and vice versa (Alessi and Magen 1988; Chiles, Miller and Cox 1980). Comorbidity with conduct disorder complicates treatment since it may be difficult to decide what the main focus of the treatment should be.

Conditions and behaviours associated with conduct disorder are listed below.

Oppositional defiant disorder (ODD)

ODD symptoms are sometimes followed by conduct disorder, and thus a large proportion of young people with conduct disorder may simultaneously qualify for a diagnosis of ODD (Faraone et al. 1991; Spitzer, Davies and Barclay 1991; Walker et al. 1991). Some clinicians have argued that ODD can be a developmental precursor to, and therefore a risk factor for, the development of conduct disorder (Lahey, Loeber and Frick 1992). Reversely, early-onset conduct disorder has been seen as a risk factor for ODD, and comorbid ODD in conduct disordered young people will often result in aggression, and persistent or worsening conduct problems over time (Lahey, Moffitt and Caspi 2003). Greene et al. (2002) found that ODD comorbid with conduct disorder was associated with higher rates of depression and bipolar disorder than those diagnosed with ODD alone. However, the relationship between conduct disorder and ODD is still unclear.

Attention-deficit hyperactivity disorder (ADHD)

It may be difficult to distinguish between ADHD and conduct or oppositional behaviour. Some see hyperactivity as virtually a prerequisite for conduct disorder (McArdle, O’Brien and Kolvin 1995), whilst others have suggested that its presence can predict the early onset of conduct disorder (Lahey et al. 1995). It has also been suggested that conduct disorder and ADHD have similar causes (Lahey and Waldman 2003), partly explained by genetic influences (Dick et al. 2005).

A study of twins has found that all sub-types of ADHD are associated with higher rates of conduct disorder and oppositional defiant disorder (Willcutt et al. 1999). The strongest association was found with symptoms of hyperactivity/impulsivity, whilst inattention symptoms were found to be more linked to depression.

Co-occurrence of hyperactivity and conduct problems has been associated with poorer outcomes than either disorder on its own (Lahey and Waldman 2003). One study found that young people with comorbid conduct problems and hyperactivity/impulsivity had a higher risk of being involved in crime than those with a single diagnosis (Babinski, Hartsough and Lambert 1999), although this finding was not supported by another report (MacDonald and Achenbach 1999). This comorbid diagnostic group also seem to have higher occurrences of behavioural problems at school, contact with mental health services, substance abuse and suicidal behaviour (MacDonald and Achenbach 1999).

Depression

Conduct disorder has been associated with depression in several studies (Angold and Costello 1993; Feldman and Wilson 1997; Zoccolillo 1992), and the rates of depression in conduct disordered young people approach 25 per cent in some samples (Steiner and Wilson 1999). Conduct disorder with depression seems to place adolescents at a high risk for future emotional, behavioural, academic, social and vocational problems (Reinecke 1995). Depression has also been found to be prevalent amongst imprisoned young offenders (Hagell 2002; National Statistics 2000).

Suicide

A link between suicidal and antisocial behaviour has been suggested in one review (Fox and Hawton 2004). Adolescents with disruptive disorders have been found to be at risk for suicide when there is comorbid substance abuse and a past history of suicidal behaviour (Renaud et al. 1999). Suicidal thoughts and suicide attempts are known to be high amongst imprisoned young offenders. In one survey 20 per cent of male remand young offenders said they had a...

Table of contents

• Cover
• Of Related Interest
• Title Page
• Copyright
• Contents
• Acknowledgements
• Preface
• Part One: Introduction
• Part Two: The Research Base – Techniques for Treating Conduct Disorder and Treatment Approaches for Young Offenders
• Appendix 1: Diagnostic Criteria for Conduct Disorder
• Appendix 2: Useful Terms for Understanding and Assessing Research
• Appendix 3: Search Strategy
• Appendix 4: Critical Appraisal
• Appendix 5: Resources
• References
• Subject Index
• Author Index
• About FOCUS