Conduct and Oppositional defiant Disorder

Introduction
Conduct problem(s) and antisocial behavior(s) are terms used to describe a wide range of
age-inappropriate actions and attitudes of a child that violate family expectations, societal
norms, and the personal or property rights of others. These children experience problems in
controlling their emotions and behaviours. Children with severe conduct problems frequently
(not always) grow up in extremely unfortunate family and neighbourhood circumstances,
where they experience physical abuse, neglect, poverty, or exposure to criminal activity.
Features of Antisocial behaviours
1. Antisocial behaviours vary in severity, from minor disobedience to fighting.
2. Some antisocial behaviours decrease with age (e.g., disobeying at home), whereas
others increase with age and opportunity (e.g., hanging around with kids who get into
trouble).
3. Antisocial behaviours are more common in boys than in girls during childhood, but
this difference narrows in adolescence.
Perspectives
Legal
Conduct problems are legally defined as delinquent or criminal acts, broadly referred to as
juvenile delinquency. This includes breaking laws such as property crimes (e.g., theft,
vandalism) and violent crimes (e.g., robbery, homicide). Legal definitions vary by time and
location, focusing on acts that involve court contact, excluding antisocial behaviours in young
children at home or school. Self-reported delinquency may differ from official records, as
some youths avoid apprehension due to intelligence or resourcefulness. Delinquent acts can
arise from environmental factors, such as high-crime areas, or internal factors like
impulsivity. Some acts (e.g., arson, truancy) are included in mental health definitions, while
others (e.g., drug selling) are not. Mental health definitions require a persistent pattern of
antisocial behavior, unlike legal definitions, which may focus on isolated acts.
Psychological
Conduct problems in children are understood as part of a continuum of externalizing
behaviours. These behaviours have two subdimensions:
1. Rule-breaking behavior: Includes acts like stealing, skipping school, using
substances, and vandalism.
2. Aggressive behavior: Involves fighting, destructiveness, defiance, and school
disruptions.
Additionally, antisocial behavior is categorized into two dimensions:
 Overt–Covert:
o Overt acts (visible): Fighting, hostility, and family conflict.
o Covert acts (hidden): Lying, stealing, with traits like anxiety and poor social
support.
 Destructive–non-destructive:
o Destructive acts: Cruelty to animals, physical assault.

o Non-destructive acts: Arguing, irritability.

Crossing these dimensions results in four categories (4 categories of conduct problems)

1. Covert–Destructive: Property violations.
2. Overt–Destructive: Aggression (high risk for long-term psychiatric issues).
3. Covert–Non-destructive: Status violations (e.g., truancy).
4. Overt–Non-destructive: Oppositional behavior.
Children with overt-destructive behaviours, like persistent physical fighting, often face severe
family dysfunction and poor long-term outcomes.
Psychiatric
From a psychiatric perspective, conduct problems are categorized as disruptive, impulse-
control, and conduct disorders in the DSM-5. These include oppositional defiant disorder
(ODD) and conduct disorder (CD), which involve persistent patterns of antisocial behavior in
youth. Other related disorders in this category are intermittent explosive disorder (aggressive
outbursts to minor provocations), pyromania (deliberate fire setting), and kleptomania
(impulsive stealing without need). Both categorical (e.g., ODD, CD) and dimensional (e.g.,
externalizing behaviours) perspectives are valid. While categories help identify patterns of
behavior and outcomes, dimensional measures are often better predictors of adult outcomes.
Both approaches provide complementary insights.
Public Health
The public health perspective integrates legal, psychological, and psychiatric viewpoints with
prevention and intervention strategies. Its goal is to reduce youth violence-related injuries,
deaths, suffering, and economic costs, similar to addressing public health issues like tobacco
use or car accidents. This approach emphasizes collaboration among policymakers, scientists,
professionals, communities, families, and individuals to understand, treat, and prevent
conduct problems in youth effectively.
Oppositional Defiant Disorder
These children display an age-inappropriate recurrent pattern of stubborn, hostile,
disobedient, and defiant behaviours. Many of these behaviours, such as temper tantrums or
arguing, are extremely common in young children. However, severe and age-inappropriate
ODD behaviours can have extremely negative effects on parent–child interactions.
Symptoms of ODD can be grouped into three dimensions that reflect negative affect
(angry/irritable mood), defiance (defiant/head-strong behavior), and hurtful behavior
(vindictiveness), which differentially predict later emotional and behavioural disorders in
early adulthood.
Diagnostic criteria
A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at
least 6 months as evidenced by at least four symptoms from any of the following categories,
and exhibited during interaction with a least one individual who is not a sibling.
Angry/Irritable Mood
(1) Often loses temper.
(2) Is often touchy or easily annoyed.
(3) Is often angry or resentful.
Argumentative/Defiant Behavior
(4) Often argues with authority figures or, for children and adolescents, with adults.
(5) Often actively defies or refuses to comply with requests from authority figures or with
rules.
(6) Often deliberately annoys others.
(7) Often blames others for his or her mistakes or misbehaviour.
Vindictiveness
(8) Has been spiteful or vindictive at least twice within the past 6 months.
B) The disturbance in behavior is associated with distress in the individual or others in his or
her immediate social context (e.g., family peer group, work colleagues), or it impacts
negatively on social, educational, occupational, or other important areas of functioning.
Range of Severity
Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with
peers).
Moderate: Some symptoms are present in at least two settings.
Severe: Some symptoms are present in three or more settings.
Antisocial Personality disorders and psychopathic features
Persistent aggressive behavior and CD in childhood may be a precursor of adult antisocial
personality disorder (APD), a pervasive pattern of disregard for, and violation of, the rights of
others, including repeated illegal behaviours, deceitfulness, failure to plan ahead, repeated
physical fights or assaults, reckless disregard for the safety of self or others, repeated failure
to sustain work behavior or honor financial obligations, and a lack of remorse. Research has
found that as many as 40% of children with CD develop APD as young adults. In addition to
their early CD, adolescents with APD may also display psychopathic features, which are
defined as a pattern of callous, manipulative, deceitful, and remorseless behavior—the more
menacing side of human nature.
Associated Characteristics
Cognitive and Verbal deficits
Children with conduct problems often have normal intelligence but score about 8 points
lower on IQ tests, with verbal IQ being consistently lower than performance IQ. This verbal
deficit can affect language, problem-solving, emotion regulation, and empathy, contributing
to conduct problems. Verbal deficits combined with family adversity significantly increase
aggression. These deficits may hinder parent-child communication, leading to negative
interactions and difficulty in teaching social skills.
Conduct problems are also linked to executive function deficits, including "cool" functions
(attention, working memory) and "hot" functions (motivation, emotional regulation).
Children with conduct problems may display deficits in hot executive functions, while those
with co-occurring ADHD may show combined deficits in both areas. Addressing verbal and
executive function deficits could help in preventing or managing conduct problems.
School and learning problems
Children with conduct problems often face school-related challenges like academic
underachievement, grade retention, special education placement, and dropouts. While school
failure can worsen antisocial behavior, it is not the primary cause of conduct problems, which
often stem from factors like neuropsychological or language deficits, poor self-control, or
socioeconomic disadvantages. Early language deficits may lead to academic struggles,
worsening conduct issues over time. These children may lose interest in school, associate
with delinquent peers, and by adolescence, a strong link between conduct problems and
academic underachievement is established, potentially leading to anxiety or depression in
adulthood.
Family problems
Family issues are key contributors to conduct problems in children. These include general
family disturbances (e.g., parental mental health issues, antisocial family history, marital
discord, and limited resources) and specific parenting issues (e.g., harsh discipline, lack of
supervision, emotional detachment, and inconsistent discipline). These factors are often
interrelated, with issues like maternal depression leading to poor parenting, which worsens
the cycle. Families with conduct-problem children often face high conflict, ineffective
discipline, poor communication, and household chaos. Sibling conflicts are also common and
may arise from poor parenting, modeling of behavior, or shared genetics, increasing the risk
of future aggression and deviance.
Peer problems
Children with conduct problems often exhibit aggression and poor social skills from a young
age. These behaviours can lead to peer rejection. While they form friendships, these are often
with antisocial peers, amplifying their own conduct problems. Early antisocial behavior
combined with deviant peer association strongly predicts adolescent delinquency, substance
abuse, and risky behaviours. Aggressive children also show cognitive distortions, such as
underestimating their aggression and overestimating hostility from others. Reactive-
aggressive children misinterpret others’ actions as hostile, while proactive-aggressive
children deliberately use aggression to achieve goals. Parental hostile attributions and adverse
environments often reinforce these behaviours. Interventions must focus on reducing peer
influence and addressing cognitive distortions to mitigate the risk of escalating conduct
problems.
Self-esteem deficits
Children with conduct problems often have unstable or inflated self-esteem rather than low
self-esteem. They may overestimate their social competence and react aggressively to
perceived threats to their self-concept, such as rejection, as a defense mechanism. For
example, youth gang members may derive self-esteem from status and prestige, but this often
fosters competition within the group. Over time, such individuals may develop a high self-
esteem that allows them to justify their antisocial behaviours. However, low self-esteem is
not considered a primary cause of conduct problems.
Health Problems
Young people with persistent conduct problems are at high risk for various adverse outcomes,
including injuries, illnesses, substance abuse, sexually transmitted diseases, and premature
death (before age 30) due to causes like suicide, homicide, or accidents. Such individuals
often show early and risky sexual behaviours, leading to unwanted pregnancies and exposure
to STDs. Conduct problems in childhood are closely linked to adolescent substance abuse,
which increases the likelihood of violence, school dropout, and delinquency. Adolescents
using multiple substances are responsible for a significant proportion of serious crimes,
highlighting the strong connection between early conduct problems, substance use, and long-
term antisocial behaviours.
Accompanying Disorders
Children with conduct problems often have additional disorders, such as ADHD, depression,
and anxiety. Over 50% of children with conduct disorder (CD) also have ADHD, which may
share common traits like impulsivity and poor self-regulation. ADHD can also exacerbate
CD, making it more persistent. Around 50% of children with conduct problems also
experience depression or anxiety, with internalizing issues like anger in ODD being linked to
depression. The combination of conduct problems and depression/anxiety predicts poor adult
outcomes, including psychiatric disorders and criminal offenses. Interestingly, while anxiety
can sometimes protect against aggression, it may also increase the risk of antisocial behavior,
depending on the type of anxiety.
Causes
Genetic Influences
Genetic factors contribute significantly to antisocial and aggressive behaviours, with studies
showing that over 50% of these behaviours are hereditary. Genetic factors can influence
temperament and sensitivity to punishment. Gene-environment interactions, such as the
MAOA gene, have been linked to increased aggression, especially in children exposed to
maltreatment. While both genetic and environmental factors play a role in conduct problems,
the exact mechanisms are still being explored.
Prenatal factors and Birth complications
Prenatal factors such as low birth weight, malnutrition, and substance use during pregnancy
(e.g., nicotine, alcohol, marijuana) are associated with an increased risk of developing
conduct problems later in life. Exposure to lead and maternal alcohol consumption also
contribute to this risk, with more severe outcomes linked to higher substance use during
pregnancy. However, the direct biological causation between these factors and conduct
problems is not strongly supported. It is believed that family background, including the
transmission of antisocial tendencies, plays a significant role in the development of these
issues.
Neurobiological Factors
Gray's model suggests that antisocial behavior arises from an overactive Behavioural
Activation System (BAS), which makes individuals highly sensitive to rewards, and an
underactive Behavioural Inhibition System (BIS), which weakens responses to punishment.
Neurobiological factors, including low arousal and brain abnormalities in areas like the
amygdala and prefrontal cortex, also contribute to conduct problems by impairing emotional
regulation and fear conditioning. These factors make individuals more prone to aggression
and antisocial behavior.
Social cognitive factors
Social-cognitive abilities involve interpreting and responding to social cues, and deficits in
these abilities are strongly linked to antisocial behavior, especially in children with persistent
conduct problems. These deficits may include issues like egocentrism, lack of social
perspective, theory of mind deficits, and moral reasoning impairments. Children with conduct
problems may also misinterpret neutral events as hostile, or struggle with facial expression
recognition and eye contact. Antisocial children often have difficulties at various stages of
processing social information, leading to aggressive or antisocial responses.
Family factors
Family factors like harsh discipline, poor supervision, marital conflict, and violence
contribute to children's antisocial behavior. Positive parenting reduces genetic risks, while
negative practices worsen them. Physical abuse often leads to aggression through social-
cognitive deficits, though genetics can moderate outcomes. Marital conflict adds stress,
inconsistent discipline, and financial strain, fuelling antisocial tendencies. Reciprocal
influence shows how children's behavior impacts parenting and vice versa, with child
behavior often having a stronger effect. Shared genetic traits may also explain similar
behaviours in parents and children.
Other Family Problems
Family instability, stress, and parental psychopathology significantly contribute to children's
conduct problems. Unstable family structures, frequent transitions, and poverty are linked to
antisocial behaviours, often due to disrupted parenting and high stress. The amplifier
hypothesis suggests stress worsens maladaptive parental traits, affecting family dynamics.
Parental criminality and psychopathology, including antisocial personality disorder (APD)
and substance abuse, are strongly correlated with children's antisocial behaviours. Fathers
with APD or criminal tendencies, irrespective of living arrangements, and mothers with
depression or histrionic traits, increase risks. Such issues are often intergenerational, with
aggressive traits passed across generations.
Societal factors
Antisocial behavior arises from a complex interaction of individual, family, community, and
societal factors. Poverty, neighbourhood crime, and residential mobility are linked to
delinquency, as adverse contexts disrupt family processes and parenting, fostering antisocial
tendencies. Social disorganization theories suggest poor communities weaken family and
social norms, creating cycles of maladjustment. High-risk neighbourhoods amplify antisocial
behavior through low social support, gang influence, and poor-quality schools, though
positive school experiences can mitigate these risks. Media violence also contributes by
desensitizing children, promoting aggression, and reinforcing hostile worldviews.
Cultural factors
Cultural differences significantly influence aggression. Societies like the Kapauku of New
Guinea, which socialize children as warriors through violent play, exhibit high homicide
rates, whereas peaceful cultures like the Lepcha of the Indian Himalayas report minimal
violence. Antisocial behavior varies across cultures and is not necessarily linked to wealth or
population density. The U.S. has the highest homicide rate among industrialized nations, with
minority groups showing elevated antisocial behavior due to socioeconomic factors, not
ethnicity alone. Family support acts as a protective factor in disadvantaged communities.
Among immigrant groups, greater exposure to American culture increases the risk of conduct
disorders, especially in U.S.-born children of immigrants.